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The Editorial.Staffl'Jditor.in.g.;h icJDr. Angd tl;.;ilriqtlerAsaqstant 17dttorDr. Vieente &tarosManau_':g l.;'dl'torDr. Annaildo (_lioiigBoa vl of EditorsDr. Napoleon Ejercito " llead & Neck SurgeryDr. Manuel Lira ................................ OtologyDr. Marl ,11o Caparas ......... . ......... Maxillofacial SurgeryDr, r,iil:_!_i.,,sSantos ....... •.............. R-hinoi)harngologyDr, Ren,igio JariJ, .......... Recttll._lructive & Plastic Surgery' ,l)r l,_shagology & ]._ryngologyI):'. Erncsl,", ,Nue*a Espana.. ....... Audiology & OtoueurologyAH maituscript_ and other edil.orial matter should be addretsed "to A,lgel t:'imquez, M.D., Editor-in-Chief, "Die Philippine JournalsJf Otolary, lgology-it_ad & Neck girgery, Philippine GeneralHospital .-- Ward 3, Taft Avenue, Manila.
ACKNOWLEDGMENTThe publisher and tile editorial .staff of the PIIILIPPIN[-JO URNAL OF OTOLARYNC, OI,OGY ....I-tEAD AND NECKS1..riCGI.:.I_,Ywould like to give due recooiition to Unitedl.:tl",_._ralofics, lnc.-Therapharma, Inc. for its support and_.,"d'_tmlcc, without which the printing of this.journal would7_,)tt_av¢'been posmble.
'1'1I1i Pll i1 IPI'IN E JOURNAL O1:: () 10LARYNGO LOGYIlEAl) & NECK SlrI¢(;I:RY1986CONI'I,NISl,M_tori,d ....................................................... iIq¢ relent's I'age , ....................................... , ............... iil'cr,_nud _Xln'rh'nec:s In FN F Sur, g_'ry ......................................... 411Manuel G_ Lira&,ns_rineutal ltearing L_J__;After Rcatical Mastoidecton(¢ ........................... 418Josefino (L llernar_,h:'z, et. alChromic l),mpanomastoiditis With Clzoh,steatoma l_rrnati¢_n: A Five-Year61imco-Surgical d m! l,'adil)graphlc Correlative Study . ........................... 42_2Jesus Map¢, el aLBromhexim! 11(7, In 7"la' C_mscrvative Management Of Otitis Media With Effusion ........... 428Apollo S. Oarcia, ct af.Insects in The Eur ('anal A S,_hzla,, 7b ,4 Pr¢_bh:m ................ ................ 432()livia (hrmcn 1".'J-mil,_Rctin, d And Tctracvclbk' l,',.,r Atrophic Rhinitis .................................. 43_Bertutbe S. Sin,g_,m. e_"al.A ( 'ttni¢_l Trial OfA (.bmbmation OfErythromycin Ethylsuccinate AndSutlhoxazoh: A cetj i bz Bacter;al Otitis Media ln Filipino Children .................... 438Ricunto t,entandez, et alTears k_om T_' Parothl .............. .................................... 446 "d{_te]-mo G. tlernandcz, et alAn Alternative (;lottic Reconstruction 1;bllowing llemilaryngeetomy ..... ............... 450d).,sse C. Baltoru_lo, et alAmehddastonua Arising I.)'om A 1)entigetou_ 4)_st ................................ 453-jacob S. Matuhis, ,'t alp_e-Opcmti_ Eml_dizatum In Juvcndc Nasopharyngeal Angiofibroma .................. 4.56'lternangiomas -- A Stugc_)n's I)ih,mnla .................................. ...... ,160Nonette 1,'h_rcntmo.l"lores, et alM_dlfied Sagittal Oste,-t_Jnzy Of 1'he Mandible: A Preliminar.v Report ................... 462l.)'ancisco A. Vic,oria, et alAneutTstrug Bone (.),st Of The Mandible: A Case Report ............................. 465(_rmencita Vera ('ruz l)i::,.z, ctal.• Rccort_tructkm Using t'ectorahs Major Myocutaneous Flap F_dlowingk.'xten_ive flead And Neck (hncer Surgery ................................... 469Adonis Jura_h_, et al.Brownout Suctton Machine ................................................ 472Rq-xJante t p.Savalla, et al.Tmdu'al Resection. A SurgkvJl Option l,br Tracheal Stenosis .......................... 4 76.dosef'uuJ liernandez,et al.lontophoretii: Instrument .................................... ....... _ .... 489l_lnmnd Fah:,m, et al.th'at (kmtery: A Treatment For Nasal Polyps &Rccurrentl.,'thmoidal Polyps .................................................... 483Norberto Mart mezPreservation Of" The Spinal Accessory Nerve In Radica/ ,v,:.ck Dissection:E_aluation Of A New Technique ................................... ....... 486Celso Ureta, et al.
t:D l l'O R L,1L77i _. 171]RD ASEAN OTOL.,1R YNGOLOGICAL CONGRE,%'l,,t :hr.,: ,,t, _)./ p)tc'nornenal adra,'tces m science and technology, the 3rd.,l_',:'ati _.)L,d,_t3.'tzgoTogical Congre,';._ .. to bo heM in Manila on Dc.c'ett_,L:,er4.ti, l 9..!,,','_.- ,_.fJ_.rsan opportuttity fi)r otl its member countries to exchartgcvtcw._ amf sf':,vo cxFeriences to solve the various problems in Otorhmolar)',_zg,;,l()_..?';)c.'idiar t(J this part of the w(jt'ld. 'l"he interchange of" knowledge willn(_r onl _ ,.'t:ha_tc'e [_rogress in our fieid of specialization but will also benefitp_.',:)plo _.Sl)¢c:',dly in Asia.t0It is, therefore, a great pleasure to) greet all the delegates and participant._tJli.$" (:()#1,!9"¢',_'3,7",; llzc j_h,lit_pine ,5'ociely (;f (Jt_da;vngoloRy .....th'ad & Neck. Surgery,lm, whL.'h J;,z_accepted the respomibility of holding this all important affairand m_)re t_arttcuh_rly to all ttzt,, oLticers at, d members of the organizingcommittee ..- congratulations.t angel enrtquez, m.OTf- -_/,_z,/ 0
President'sPageDearOdleag, u t's"Like all Or,vs,' _ h:; have' preceded ?tie in this exalted position. 1 assume the leadership _]our society_'lth c_)nfitc:it'>. .'_,,:,._ti_.,__.,fgaiet)' and anxiety, of jubilat.m and trepidation.t,or m
1_ rbtL Ii. Aamtomic DefoonityJtsa_of' oto. A. Congenital -- fatSal mymmetry; atn_siaIk'ad & l_c_.iS,,_ry B. Acquired -- deviated gptum with hyper.trophicd inferior turbinates, nasal f_zctur_.Ill. New Growthx of Ncme and/or SinusesA. Benil_ polyps, papillomas, adenom_,PER._)NAI. FXPERII:_ICI'S IN tdJ_m)m, ch(md.mlas and oilier benigntumors.I'_N-I' St JRGL'+'RY B. Malignanl -- epidermmd carcinomas, adcnocz_or others:IV.Fonagntk_Manuel(i. lint, M.I)., F.P+C+S.* V. NasophatyngcalA. Adenoid hypertrophyB. Tumon, -benign and malignant"there are causel of chronic nasal oh_Iruction.Ihn+evcr, Ihi_ is bey
_, the inf_or turbinal bone vari_ inPosition thicknem. Some inferior mddmd bores are 5-7 tram.thick but mine ave 1-2 rnm_ thick m paper thin. TheAs s_mn as the patientt are put to dc_p under _en- thick onet me much eJer to remove _rgi_ally, andoral anesthesia, the ol_a'ating table it mamptd•ted to • the thin ones a_ much mote dif_ult to dissect becausetetrti..rcclitmdposition with the head Imd.l:_:xly in• semi- theybrtak emily and they mere to be more adherent.rec_nbcnt p_iticm, and tlw legs hi#mr than the but- In the thin ml_, the mlmmeoml tisme is much thickeLtcc'ki to p_ev,',,lttfile patient frtm_ dipping down the and mmetim_t it may be mcatrary to do a partialot_r_tirql tattle. If the paticat ia operated m_d_r itx:al .irdedor tmt_oetomy cm the matcro4nfedor end to as toa_d tor.ital anesthesm, either the: _ae potition aa in give in adequ_lg aisway afar tl_ Ol:mrarion.412
Technique of Submuc,us Resection of I_¢.r;,_, ':" "_'" .In fcri,,Jr "['urbinatc. _,, /,,,:r,Tile l¢Ch/lt.._tl,: (_[ _,ubmuc_u_ resection of the , ..... ".,..i.l,:ric)r ttuhinal¢_ i',,a, l, dl, .,_,.: \ ....... .4.... ,,lliqll m:,, ,_¢1. I)_epale .;,),,_, ,:) t: x,,h_ainc bOlllti4..rll with ,,adletlalm, l : l!}_j¢}E'qL /' l,2. ,A:;l>ilate lOot.' _t rids scAt,ttion into a 1Occ. _' 'syringe f.r lat_'r rise .... : ! _ . _. 2.._-'T'._3. S.a:k tiny na:,,d .;'.rips cff gauze in t.he 1% "... ' _' 'xylt_:aim: s_ium,x_ wi_,h adrenalhle, 1: l10,0t._0. ,_ ," ' ....4. Gently pack the n:c';::l cavities with these soaked _t_.... ' ...,....,.;_.dF'ig. 6. Front View of Incixicm on Inferior Tutbhlate.troy rla:ial _trii',s. TI.. object i_cte is to cut duwnthe bleeding :.,rot Iv dec,m._cst the nose so that 9. This is followed by clissectmg the inferior turbitkesur!.yoa can h.w_. :_c'.ear view dunngsurgety, hate under tile periosteum to expose the inferior5. g'i'nlc x_aitual_ f,r tltc packings to lake effect, mrL,inal bone by using the sharp Freer's eleva.illjeet luc;dly tit,.', caudal c:'.d of the septum lo lor an_l the suction ekwator (see Fig. 7),bl,._k m to cut dt)wn tit..: bleeding Item the I_. +,- " '.'.,ethmtM,d, the l;_,,.'_.'_l, t.l.c _,_,:a_er palatine a_tdKlsselh..Ml'+;the mcdi,_lx,lsrul.llsph':,tt.,i,alatit,plcmt,st;(frolnves.sels).the anteriorI alsc)_)!:i,'..:!:'il_f'iltrar.¢: sonl._ :,llluti_)l'l to block the mlterior .' ,elhr]mid,_J art,'r_es mjectint,, between tile upper;rod tl,c l,_',_ct I:_lc_.l ,attilage$ through thehakim v,;:ml,.1,.', lhe packirlg_ ate left tm at ' k_,,period ,.,l" 5.7 iht_ult_:s ,trld are removed with t_,% . i- ithe [);ly_.fflt_t It,lCel)S. IL " ..... .,,,,,,,'," "'_'_ "-- " .claus reseclion oJ" nas:d s::ptu,n before proceed- _., ;.,irlg to sublimct_us resection of the iJlferior ........ ;....'..._turbinate_. I ',tin s_,,:, all of you are n];JStelS llgu_e 7ill subm_.lc_las rcscctiorl of ilasal $eptrdln, st? thisdt._es nt,t have tt, be thscussed, lO. Wh,:n the turbi.nalbone is exposed, file anterior7. 'Ihe next slep atte_ septoplasty is to infiltrate attachment is broken with the chisel. Thislocally Ice. of xylocaine,adrenaline tolution to should be done gently (see Figs. 8 & 9).r&e anterior tips of both inferior turbinates, ll_-" r "¢: "_'rs"_l_8. Usually.I incise theI starta]_lesJtnwithtipthec,flc!'tthein'feriorhfferiortvrbinate,turbit_.:iter !'_........' :'vertically ab_:_ut 3_-]r,m. behind fl_e limen nasi _. _-..._,( thi: seems to blem_ _,,ith the _mtetior end oftile inferior tulbir_ate). The incision is dotie .,,"with B-P No. 15 !.:nil'e-,rod is carried down tothe inferior l.rbiwal bone. Be sure the petio- _, ....... ...stet]tn is inddc(l (see (;is. 5 & 6). .,,._. ",e /" _ .. Figure 8(':'....-_IL. ,,' _ M.._..f "":'trig, 5. Lzlteral View of Ir.:i:,l, ,n on Inferior Tutbinate.413
12. The incised wound does not have to be sutured.It falls together again, end a piece of soakedtiny nasal stlip Is placed between the septumC.'" / " ' and left inferior turbi.nate.....;'-""". ,. .. 13. Similar procedure is done to right inferior.. :, •turbialate."""_'_e,,,..l 14. When the procedure is linished, the nasal carl-/' l) d '" "'.,:i_',_ tics are packed with vaselinized strips of gauze.• t.,..F,,._," . , . The packing is done witil the help of rite wider•--, "" *_ ".:_ the incised wound or flap from opening again(4,'or displaced.'_ 15. The nasal packing_ are left for 24 lmu:s and.........:..;.'........_. . :.,_ andarelongerremoved.KillianThenasalbleedingspeculumis usuallyto preventveryt tg_,e slight and can be controlled easily with cotton11 With the Vienna_Storz or Killian (2") nasal balls soaketl with Neo-synephrine 1/4"r_nasalspeculum to spread life incisim2 and soft tissues, solution. These ioaked cotton balls are left betdieinfeno): mrbir, al bone is dissected both rite ween the scptum and inferior turbinates for am(tdi,Hai)d lateral sul tac¢_• 'l'hi's should be done lew minutes. The bleeding usually stops, andc:lret\.dly and gently to prevcr_t laceration and the nasal cavities are cleaned with the nasalactual turbinectomy. ()i_ce the imterior 1/3 of ruction.the inletior turbinal b_me is exposed, the ex- 16, The patient is discharged from the hospital oneposed inferior turbinal bone is grasped with the (lay after the removal of the packing to be surestraight Blakesley's lotcel)l aJld removed (see that there is no bleeding after the removal of'(Figs. 10 & 11). The bleeding during the pro-the packings.ccdure is usually ,)i)_itmtl. The posterior 2/3 of 17. Complete heilingusually takes about a week,the inferior tud_il_al b(me is thin, weak and ve[yadherent. This does not need to be removed. ResultsOut-fracture of the posterior 2/3 of inferior.rut.bmal bone is done with the blunt Freer's eleva- Table 1tt_r to give an adequate airway.__"*'3 4.._' ................:..,,,',-i_"' .. Yegr1964196519661967, NumberOpenttions.9811235212 of_.' '. - • .", _ '_'.... -":"""'__ " " '_;"_.... 1968 1969 140 151, ,,...... 1970 126I' !'.
The partial h'nproverncut is attributed to tile early 6, Systemic _ mcondary to bcm.-hcmo_yticyear.*,of operau,.m witm),t l)r0per selection of ca_'s, streptococci infections (rhemauttic tL_er, rheu-Pali::,nts with a!lergl,' am] having _ptM deviation with nuitic heart disease, glomerulonephrim).h_,l,.:rlr,,phicd mt',:riiJi tud,i_,:_te, are lmor caJtdidatei[t>l t]_i_ ol,c_al_ m t_c,au:ic _]t¢:mq_r_wement is t_;IJy Anatomy_h_+, I.h_cd _,tle_ the ',dL'tb:'_:_i_t_>pcrlycontrolled.The palatine tom_ils8re located in the toraillar ftmaC_,Itl mindicati ,>n,_ bounded an tetiorly by the glotaopalatine arch or anteriorpillar and pc_teriorly by the pharyngopalatine arch or1. Naial allure. Thi_ :_h_,uldbe properly ctmtrol- posterior pillar and sup, riody by the semiltmar fold.led fir, t bcfi_rc t]_c tq>¢raIitm. This contraiud.i- lnferiody, it blends with the lateral wall of the orocati_mis oMy rclalivc and not absolute,pharynx. The 'tontilltr capsule is formed by the phap/nh_alaponeurmis.Outside of the capsule is l
5. Xylc_ainc 1% wit h adrei)alJn¢, I'I00,00 about "='"',_' ....... _':. ' .... ;. ' _3_15.10 ¢c. is infiltrated around the tomillar 7 ' .h_ to cut dow. tile bleeding during the \'.. /"t,iocedure.(,. fh(' a_istant h_Lt_ the YankauersuclJ_mtoIrtlact 'd_esoft palate to _mc side./, 'lhc uplw.r p,_tc _)f mc t_>l_,iiis i.,.rasped wiODI_m'_l gtaspcl o! AIh_. IL,I,.:,_pol iollsi] artelyciamp. The t_m_fl i._i)ullcA meth,.dly to expo_ . :ih_Itl_e muc_a bctwcc, llw koslclior pillar and [,q , ,the _atermr pillar [lh,: phca ,';t:mihmaris). [¢!,!_-;. h_ctst_n was done _llh ,i I_;astl|)arkel No. 12k:Mc. The inc,_,ion st:ul_ with the l-m/¢o.s.a .... ,zp_)steno_ly bctwwen fly.: p,>slcrior pillar and Fif.ute 14tJ_¢tonsil, and the krfilc i:_thawn upwards and 'I
16. When the tonxille_:tomy ts completed, the ton- 4. I]ollinshead, W. HenrT. Fascia and Fueitlsillar fc_ssae
1_, v_,_- Materials and MethodsJ,>ufof Oto.ltc3,__ Ne:k Patients with chronic otitis media '_'ho underwent5.:_¢'r_ radical mastoidectomy at the Department of Ot(}rhinolaryngology,UP.PGH Medical Center from January toDecember 1982 were included in this study. Puretonea_Jdiograms, both preoperative and four.weeks post.operative, were done for each patient. Patients with,SENSORINEURAL IIEARING I£)SS AFTER mixed hearing loss noted preoperatively were excludedRADICAL MASTOII)I'CFOMY * from the study. The material ct_llected from thesepatients weleanalyzed.Results and Discussion.losefino G. Irteraandez, M.I). ** There were 53 patients in tttis series. There wereRomeo L. Villarta, Jr,, M.D. *** 28 males and 25 females with an average of 13.7 yeats.Victoria C. Sarmicnto, M.I). **** All of the patients underwent radical mastoidectomy.The operative findings and operative procedure donewere similar In ",dl of the patients. The preoperativel,tepa_ation used was povidone-i_line scrub. Bone worklliade use of high speed drills. The ma,:toid cavity wasIntroduction packed with chrorampheificol powder and gauze impregnatedwith tetracycline oimmen[.Surg:fy l_a_ always beeil considered the mainstaym the treatment of chrt_ni,: (_titis r_edia. Because of Of the 53 ca.ses, 48 patients did not develop sensoinherentresistance of the chrome pathologic processes ni3eural hearing loss. Five patients (9.4%) developedt_ medacal therapy, s;_rgery features prominently ha the _nsorineural hearing loss. One patient (1.4%) developedu_:atment of chronic o:itis media. The surgical proce- profound hearing loss, while four patients (g.9%) dev.dure usa:dly perft_rmed i_ either a classical radical or amodified radical mastoidectomy with or withottt tympa- eloped high tone perceptive deaflles_.nt_plasty. As well all know, the :,bus of sa_rgeryinchroniccaius media are three4old. In their order of importance, The first pattern noted was that of proft_und hearmgloss in a 20-year-okl male who underwent radicaltrey are: ruastoidectomy in the left ear. tqgures I and 2 showsFirst, prevent or control c)togcrdc suppurative intra- the preoperative and postoperative audiograms res.craIfial complicatious;?ecfivdy.Second, obtain a dry ear and eradicate disease; and FREQUENCY (kJ[.Iz)'third, preserve or improve heating. _5 .5 2 4 8Several authors have observed the devdopment ofsensorineural hearing loss after ty1_t'panomastoidectomywhich aggravates the pre-existing conductive hearingloss 0 --among patientL We have uildcrg_me this study to documentthi:, obsetvatiorl. 20 [ """ ii i { I ''_" ii [! " ''*_[ "- " "_ ........The objectJves,0f this study are:401. determine the incidence of sensorineural hear- :¢.kzgloss after r_dlc',d mastoideetomy ;and _ /_2. determine the patterns of scnsoffneural h_ring _ '_," "- ' "toss.°Firs_Prize*'Formerly Senior Resident, Dept. of Otolaryngology,U.P.-P.G.H.Health SciencesCenterI00 ,.• **l,'uzloe/']¥ O_ief Resident, Dept. of OtolaryngoiogY,U.P.-P.G.ll.lieaitt_SciencesCenter•,**Senior Resident, Dept. of Otolaryngology, U.P.-P.G.II.i{e;dthSciencesCenter.110'Fig. 1 Preoperative Audiogram418
I:RI'OUENCY(kl iz)I'IREQU_qCY(fHz)2.5 .5 1 2 4 8 .25 5 ] 2 4 s0 : _ -,0 -m604o ............. ,\¢ t- _ m 18o jr. dr. oz.............. _2 I00-710o f: :d__ 110110 F_. 4 l_mo_,ffiti_ ^udic_._,nFig. "._ Postopezative Atidiogram Review of the _>e_ative record of the (afly patimtwho lind profolmd heating loss in 53 cas_ under studyThe secorld pattern, _';_n ill fcx,r cases, is exem- revealed that in this operation, the_e was a cholesteaplificdby the pFet>pcrative aJld ptystoperative audiograms roam which has l-died the anuum, ealarged to 3 times{shown m Ftgtzres 3' and 4)
cmpbcaled _thanoi an(] povkl..me.ic_lin¢ as p_bl¢ w_ks poztope_Uve period when the audiograrns wereototux_c cht_dcals in anunals. Ax_lL'ieptlcs could col_i_ in done._Nxtact _ilh the I_ntal_ ol' lhe cochlca . tie: oval andi,'LIIl(J _,¢II,t()W_ alh] dJI/LI_,'_Y the IUli/ cells. Widz the The possible caroms of sensorineural hearing loss,.2d_t_,. _,_tdctcq,_mt_ .gs i_, p_,_.hmc-i_giinc scrub, tire altel lylnparloma'ttoidectomy sh
ear, in Paparella and Shumrick (eds}: Otolaryngolog_.Saund e_l(Philadelptxia) 1980; p. 18]9.1820._,_ar_lWI) in Noise-£nduccd hearing damage, blI'aI_aI,'Ila and Shum_ick (t'.ds): I_t,da(.imgology. Satmders(l'idl:,dt'll_hia) 198(); p. I'/')!L421
h, vim ., other patholo$ies ncceatitating surgical inter.!,:,_rof Ot ,_.verjtion;_ ,:,,,,.tt N_:k °_.:,_.o' b) readiologic m_d _urgical reports of cholesteatomaagainst subsequent confirmatioa by histo.IJathologic examination ;_qd(HRONIC "IYMPANOMASI'OII)II1S WI'I'II c) tt,e possibility of surgery ba_aed prir,aarily ont. tlOLES'I'EAIOMA I'ORMATION: A FIVE- clinical evaluation.YI'.'AR CLINICO-SUR(HCAL ANI) RADIO-GR APHI(." C'ORI¢.['II ATIVE STUI)Y * ' ResultsAmong the 38 cases studied, 14 were males and 24Je,,,us Mtqm, M.I). ** fe,n:des with ages ranging from 2 to 39 years. The meanage incidence was 14.9 years. All cases reviewed haveFere.,,a Wilma Cunanan, M.I). *** chronic foul-smellmg ear discharge. Significantly, 22Vcrgel Angelo I)ij:,mco, M.D. *** 15-_9,", .... _.j wele histologically confirmed cholesteatoma'=(Diagram A). These developed in 4 out of 7 (57.1%)cases with marginal perforation, I out of 6 (16.6%)cases with central ix:rforation, and 17 out of 22 (77.3%)ca_s with no report of a tympanic membrane perfora-[ntrodurtiontion. None of the 3 cases with attic IJerft_ratitm developeda cholesteatotna (Diagzaun B & C).lit ._ crisis clJvir'_._nnter_t ',v[_cte the government- .._i,_,n_ored pre-necd hc,dth in:mrance _ystem (MEDI- U,fortunately, only 15 mastoid x.rays were avail-(ARI:II is inadequate, tixe goal of ror,d health care able [or analysis (Diagram D). Six (6) presented withdehvery .dm,_._t alwav_ _:tlfcl:_. l'hc mc_easing cost of tadio_rraphic evidences of a cholesteatoma while themedical :u,t laboiatuly :.cycle*', a:, well as hospitaliza- remaining 9 were reported as 'mast,oiditis' withoutt:ic, n will _ee to that. mcntionmg the presence or absence of a cholesteatoma(l)iagram E & Table 1). All 6 (100%) radiographicallypositive case:_ were eventually confirmed surgicallyObjcctive ar,d histopathologically ('Fable 2).As ;t c_st-cuttin I"iliea.tllt', this :;tudy was mtder-_.akettis_a_ 'attempt 1o th_covcr ally corrclaticm between Of the 9 radiographically negative cases, 4 (44.4%)tr_¢clivaco-,,;urgac',dfi,ding,., in dtr,.micaily discharging wcze reportedly cholesteatontatous on surgery. Ofeats and the radiographic ret,orts of a cholesteatoma these, only 2 (50%) were proven histologically. Para.doxically, in the remairting 5 cases with no operative...._that ma_id x-rays c:m bc minimized or altogether evidence of a cholesteatoma, 1 (20%) turned out to be2._;_:ns' with. . positive on ]dstologic confirmation (Table 3).,',laterials and Methods In the 23 cases with missing radiographic reports,1/ have operative findings of a cholesteah_ma whileIt,:c_uds _!"38 pati_mts v,ith chrolli,.: tympanomasto- only i 1 (64.7%) were cotffi,'med histologically. In:.htis a.hnitted at the MCL' lto_pit_l over a 5-year addition, there were 2 {33.3%) confirmati,::ms amongi :_i_,l fi.m Jaly 1_)78 to Jut_e 19_3 were studied, the 6 cases with no surgical report,: of a cholesteatoma!'_'llillcu[ tl'lla ;)S 10 ;I,?_C,',,C._.. ptCSCIICC o1' C:II' discharge, (I)i:tgraln F:and Table 4-A & B).,:;,_X'I;t.C al;d [ocatioll ol t_vmpa_Jc mel|_bralle l)erfora -!; _:_,radi,_i;1,_phic_el,,_rts, ._url'ical lindmgs, and histo- Interpretation?,,dt.l_,_:-: diagm._._is were l'a/q_Jalt.tt. The followi,g,,,aclat_,,ns were studied: 1) A surgical ear can be evaluated clinically basedon the presence of a chronic, foul.smelling eara) lo,_'ation of tympzmic membrane perforation discharge irrespective of the type of tympanic,rod incide,ce ,>["c]_ol,:,>tcatomaformation a_ld membrane perforation.2) No interpretation cart be made on the basi_ of"2nd _)rizt_ 4th l_.c._idcnts Scientific Research Contest in the type of membrane perforation since 77.3%Otolaryngolo_;y held on Oct. 12. 1984 ,it the Army-Navy of cases made no mention of any tympanic_l_t, membrane perforation which is most unlikely.,'l.._c;ly 4th Yc.tr Post_,rath,atc 'l,;tim:e. MCU-I"DI A lllore accurate physical e×arnination andM,'d, ,d I'o.udatit_tl.• " t tuu:,'_ly lnt¢_n_. Mt tl.I 1)1 Mt'd_,'al I.ou.dation, recording should be emphasized.422
" 3) Mastoid x-rays simply provide further evidence Conclusiont,f a middle c;u/mastoid pathology. They wereshuw. to t,e IU09:,reliable only w|lcn there arc Chrot|ic tympanomastoiditis is a stirgical c_p_.A_ivt: Jtrp,,tt,; _,f cholesteatt)nla i'omiation. ¢omm(.,nly ass|rotated.with cholesteatoma form;lJ,m,, aJJ),,, I.£:,ih',,Jt,,mas wele found in 3,L3% high degree,of accuracy carl be atti6ned on shnph,_1ih,..r uhu;eJ,q_lii,.:allyaef,ative cases, evaluatiou of the character of utorrhea irrespeLbe Ic,caUoll of ,01e tytlq_anh: membrarl¢ pert4) _.'l,t,l,;tcat,',ma', V,en,'. ctmfirltled in "/[).,L'_uf |_Xpensiv¢ tadiogtapldc studies of the mast'oids,t t: u ) i,,r._ive cases, ltowevcr, they were mitiimized or altogether dtspensed with l_b_ceth_3.'.!":_l:,_ nnut_:d in "'; _,, of smgJclally negative only provide further evidence uf axl expectedc,_.,c:_, pathology. This effects reduction in the cost of, care without sacrificing quality. Cases were ci5) Alttu,ug.l fl,cr,:, was a notable n|ag4fitt,de of reasons were given.radidugic az:dsttr#c:d misdiagnosis, the hJstok)-_,lc reports _evcaled various pathologic changesthat necessitate surgzcal intervelltiol_.DiscussionDIAGRAM A: L.._CIDI[_ICi OF C! IOt,l_ C'F._TCIgA WI 3_ CA.,_ 5TUD_By hirtue _l their intintate anatomic relations, _t,n'ttcxot.t_'rat-;_(_7._)Jorlg-standmg infccti_ns of the middle ear almost alwaysinvolve perfora;ioJ:s uf the tympanic membrane alldchan_jes iu ,,he mu._t,_idair ceils bwariably resulting inIII_IIO_.].OIOUS ,lr._in.l_.. 1,2,4,8 Most C0111111OI1])', chronicof tl,e a_quLtc..1:)pc.l ,8 Tats results from squam_t.|sepitheliala tfmp.mtcirav:tsi,.)nlll_.'ltlhl.tlter theperl'oratiot|.2,5mastoid air cells.6 .7 ,9by(Rarely,way uf L....__ _n_kh_coxq!,enifiddu_l,stear,mta.s .Juvd61_ as a result of 'cntlap.mexit' tK cpithehal cell,.; behind an int:|ct tympaldC"l')'mt_;llflt, ' I,clf_l:ttlol_s _lllt2/ Ire extremely Slltall ariddifficult to wsu,di/c _tu._,Ctq)y, _equirmg a Illore thorougharid rnet!culotl._ e:,,alninahun. 1,5,8 "][Msseems to collaburatenmt;h _ith our obsctwation that a considerablenumber of hls(olugic',dly confirmed cholesteatomas .....,_..........._._j.-/occ'urfed in cases with tic)mention of a drum perf,'._[adon.The radioL_raphicdiflbtentiationof a cholesteatoma]roIII a glar]ul:tti_m Ii:,:,LW., a+lothcr cotnl'llOll sc(iue];I t)f -- lfflllOtff t'll_lL_,-na'lC_.A('tl,l'll)chronic tympa_oma:,t,iditis, is Paced wit|| lil|lch tcclll|tcaddifficulty. 12 Moreover, the0" identification couldonly at best pmvMc further evidence of a mastoidpatJmlogy and does not i_ ilsclfconstJtute a prerequisiteto su[gicd inle_vcntion.8Unf,ortunately, medx,a;d management is of littleimportance it| the treatmentof chronic tymp,'momastoiditis.l,4,8in view of its insidious progression and thepos_bility of int|a- and cxtracrani',d cuniplications,chronic tympanomastuiditis becomes an absolute indicationto surgery.1,4,5,8,9 To treat a sur/_cal ea_ medically,and a medic:d ear surgically, is not only a seriousn_istake but can constitute a c_iinc in itselfl I 1423
( + +_n ++I h, rz+,+.l)u_ 4,++ +__+,i.+ 'lh_ I_'fi,+J +[n,,tl l+ _ ......_,'b ,'-_I J".* t (.)_ 4"t'_,_',ll ");i,_1_ _L_)Kh),b._, IO1_PkOf OIA_KA.M U: M_TlUm_Ir)ONO_ CASESWJTH ANO_t)I'IHOI.;'] X,RAY RE_R'ri!.......I ........ , ......I'T_,IflIlliJ ......... / '\\,\N,\] ', ,,j,Ib ,N1)y no \-r,)yI¢)lPf+l,lt_++ll" R^ ;_)t m (" _LR{ ")+l.&+I l(l$1()L _I _LI'_.K_I,' UFl IK)L151 i_A1¢,)__,IN ('A$1_)11il _, KAY _T_L)r!3" !............... l /" \"
, , ¢,_"]ABI..E t: R.At)IOI.O(.A. DIAGNOSIS IN 15 CASES B. RADIOGRAPHICALLY-NEGATIVE_,_1Ill MAST(')II) X-RAYPATIENT NO. RADIOL()GIC DIAGNOSISA. RAI-)IO(;P.AI-'III('A[ L,Y'4'()SITIVE 1 Mastoiditis, left, with'no evidence 0, •......................................................................... cholesteatomaI'A II[:N'! Nt.) ]
IABLE 4:, SURGICAL AND HISTOPATIIOLOGIC REI_RTS OF CASES WITH MASTOID X-RAYSA. SURGICALLY F'OSITVF.CASES.,,O. 1" SURGI('AL REPORT HISTOLOGIC REPORTCIM with CI', LCT, granulation tissue with acute and cltronicinflammation4 CFM with CI', R Acute and chronic inflammation6 CIM with (.q', L C-I', chronic mastoiditis, L7 ('I'M with CT, R Cq"8 CfM with CI. I. Granulation tissue with acute and chroaicinflarmnationII ('TM with ("[', I¢. ('i'i3 CIM with granuhititm ti:_sue, R Osseous segmentslb CIM with C'F, R (.q', acute and chronic inflammation17 C'TMwith (__, R CT, acute and "chronic granuhtion tissue,acute inflammatory exudates:O ('I'M with ('T, L CI"22 (71"Mwith CT and gtanulaticm tissue Osseous tissue fragmentsf'_)rnlatii)n, 1?,23 CIM with t'Tand L'J'aulatitm tissue Stratified squamous epRhelium, keratinizmg,l'ollllatl_)ll, R with severe chronic inflammatory challgC$25 CIM with CF and subpcriosteal abccss, L Acute and chronic mastoiditis28 CIM with CT and gr:mulatkm tissue CT, acute and chronic granulation tissueformat ion, L30 CI'M wtth C"I', R CT33 CIM with CT, 1. cr36 CTM with CT, L CF ,.:bcgcttd:Mchronic tympa1".ml.tStoiditischolesteaiomaright]eft"fABLE 4: SURIGCAi.. AND HISTOPATHOLOGICREPORTS OF CASES WITH MASTOID X-RAYS (continued)B. SURGICA LLY NEGATIVF_ CASESNO, SURCIC'AL REPORT HISTOLOGIC REPORT3 (H'M with glanulat ior_tissue formation, R Act_te and chromc inflammation, R mastoid1_, ('TM with listul;i f(nmat_,,n aml facial CI', acute suppurative intlammation, Lnerve paralysis, 1.19 (TM, sol,It, tic, tt CTM_.21 C1M with granulatio11 tissae formation, L ,Tr, granulation tissue, acute and chronicinflammation26 (q'M with fistula formation, L Acttte and chronic inflmnmttion27 CTM with lateral sinus thrombosis Chronic mastoiditisIHend:IM ; chronicmastoiditi_: ¢holcsteatoma: tlt',hIkit426
REFI_RI'_NCES1. Adams, G. t.., ct. al. [:uudamet,tals of Otolaryngo-1o_. 5th Fdithm. WB S:tL,nder_ Co., 1978.2. IhJckingl,am, R.A. l'.tlolo&2/of Middle Eat Choleslealolna,AKoda_httm_c Sltldy of Dath(3gelmsi:i,'IhcAnn:dsof Otvlo_'y, Rhmoloff& l.aryngology./7:(L1968.3. Friedman, 1. tipid::_mmd ('holcsteatoma and CholesterolGtanuloma_ lixpvtimcntal and lluman. TheAnnMs ofOt_t,q:y, Rtun
t;mups, A and B, consisting of len patients each. 'the firstr.rou l) (A) was given all antihi_[imine/dcc :w.,us th:,t eu,•+d c;..::,,m.:¢ ,.it the middle ear a t¢)tal of 22 ears were included m tilt: study+.:_:_l,., +h,t+ugh the cu:dacJ,,uJl lu}ar.ogtam and,.,,i},r. ,._jJ_:/a.tib_ot. '_,,l_b,l,.+I,(,., I (6.t,(,'/,) with "lype ('. (in the ,lth week', a total ofIt +Materials and Mell_mls 'a (6(Y/o) ears have mlprt)ved, 8 (53%) to Type A andI ((,,(i6%) to Type C and 6 (4LYe) temair_ed Type B.Iv,,,_tty paticntsw]th (Jb,ll sct..n :tt tllel)epa_tmcJil_' I,N I tli'-l'(.;l] f,>m Janu:_r), t(+ .July ]984 were includ-. -fable and F:ig. 1i,ila II,estmly. Ac¢++_l,c .I,i'_l_+,,':md physicalex:lmir_._ti,mv,a-_ .lade. lJa_clmc ],ulc tone audiometry att(I Group A: '['YM|'ANO(;R,AM;m[_da_ce tympanon!etry wc_e also (lone on these l,)a- Initial .2 weeks 4 weeksta,ats, fhese patients were randomly divided into two TYPE A ..... 3(20%) 8(53%)............................................................................... I'YI'E B 15(100%) 11(73%) 6(4tY_b)°3rd l'rUc. TYF'E C -- 1(7%) 1(7%)"lorm_'rl¢ Scl,i _r lG...',ltltnt, l)cpt of OtoLn-yngology, U.P.-EL,,'L ilralth Scicn.cs (enter• +'Scni,,+ R,.,,,idcn'q I)qp[. c+f {)t,:_l,_ryrt/_!t>lugy, U.P.-P.(;,II.II,...dt!t_,_.lCllt't,.x (cnlcr428
,Table imd Fig. 1Group A:HEARING IMPROVEMENT2 weeks -. 10 (71.43%)..... ' 4 weeks - 14 (10(YY
• f_rt_nded .cortsidered antitfl,_tamine/decongestant et'PJ, ear effusion it essentially a mixture of ex.udat, and;,_ie, for OME. Although contl,,:ting studies on the use mucus which becomes i_ereasingly viscous, the antihis-,/t_lis ct_J:_bmatitm|_,¢c been reported by some authors famine/decongestant combirmtion has a synergisticd'a/itel,.i_, Kcl,n). Thi_ _ttll _tm,.:ht,_v ,cmains a main. effect. The _creticm is dectea_d with the antih_tat',v:lit II,,' medical lllart:tl,,'llt,:d
M¢dia with Effusk,n. Ann ORL 89: (Supp)68:278-80, 1989..8. Lupovich, P, Ihrl,',m:_ M: Symposium on Prophy..laxis and "i'v_atment of Middle Ear Effusions- Thei':dl,:l_h,,'xi,,h_'v ,,1 ]'ll'usion its ()titta Mc(ha. Arm{.)RI... Hq:l(_.17... 3, 19_-',_)').Ma*.Htlh:s, _'q¢lla, M [.L I'¢lSt_tla] ('OIisol|.I0. Metal I)., M.tchlc h : lhc use o1 an aliiihistamincdccongc:;t:mtw. c_t(i,ltction with all anti.,infeetivcdrug in t!_c trc:ttnwllt uf acute otitis media. TheJournal of l>cdi;:liw:_. 101. 132-6, 1982.11. O'Shca JS ¢t _d: Childhc_od Serous Otitis Media.Clinical Pediatric":. 21:!50-3, 1982.!2. Qvarnbetg Y., Palva '[.: Active and Conservative"lreat.rnerit of At.:t_tc {}t:,ti..,. Media. 89:269//0,19bO.13. Sentuiia B. ct a!: l_.ep,_t of the Ad Iloc Comnxitteeon Defirrtd_ns and ('lassificalion of Otitis Mediawith lille;st, m. Ann ()ILL (Supp 68). 89 3.4,1980.14. Schuknecht ItF, Zay',oun G., Moo C., Jr.: Ad_.dt-Onset FMd in the I .}mpanomastoid Compartment.Arch ORI.. 10,'..:759-65, 1982.15. Schwartz R et at: "]'he l,icreasing Incidence ofAmpicillin.Resi..,tanl II. influenzae. Jama_ 239:320-3, 1')7,_,O16. Shurm PAct al: r)titis Media caused by non-typable,Ampicillm rc,,_stant strains of H. inthieltz:le.Journal t)l I'cdi:,tli,.s. 88:t_46-9, 1976.liI. Slrfith AI,: Altlib,_t]c:_ aJld Invasive 11. lnfluc,tz_te.New ENG J Med. 294: 1329-..11, 1!)76.18. Syriupordore J.: Incidence of Ampicillin-Resistant11. Influcnzae in Otiti:_ Media. J of Pediatrics. 89:838.41, 1970.It). Thomsell J el al' l'et_icillin and Acute elitist Shortand l.xmg Term Results: AnnORL, 89:271-4, 1980.20. Tos M: Middle Ear Epithelia in Chronic Secretory()titis. A¢ch, Ol_.t. 106:5_73-7, 1980."!1. Tos M. i'ath_gcnesis and Pathology of ChroricSecretory Otitis Media. Ann ORL. 89: 91,6, 198022. ]'u_ M.: SpoJ_tJtwt_us Course and Frequency ofSecretory Otiti.', m 4-Year ()ld Children. Arch ORL108:4,9, 1982,23. Wiag, L.- Bisolw_l_ 'and Attired ia the ConservativeManagement of (,lue Ear. Medical Journal of Aus..italia. 1:2_q-9(), 1978.43_
_ _i Of this number, 44.08% were inanimate and 38.72%,k.,_,t,_tOto were animate foreig4_ bodies. While inanimate objectsi.._._,_ A ?q,.cl.seldom calls for immediate attention, the ammate foreign_,v,,-:y bodies ... mostly insects -- are urgettt emergencie_ forJ'ea._,_l_:_ already stated.iltde's Fttndame,llals of ()ttdaryltgt,logy ctJvct,:d tileentire subiect of ear foreign bodies in
olcoP._,Lt,t t:_;m¢_a(w..._,m A,_)less than halftminute(ice"FableI[).Thiswas fotlow_by kerosene,alcohot,baby oiland cookingoilint_orderofpotency.-_.._ 1_i1 ,f"_ woist smothering agerlts as both i.ll,.;e,:t s .....anLsand cod/ , _D' ".,I_.\\ ' ' ' "(71' roaches ... were ob_tved to l.)ealive after tO minutes.:6 _" pletely immobilized.I-.....lilOWilfiFUl. _lO'rltlSO J_WS _" CdOP_NTE_ d_('?ockroadies alid :li;ts -- the two conlnK_r;l'ear¢;ttl:ll intrudcc,_ were ittilii'ed for this investigation.I:at:h specie was ieMcd twk,e alid the time it took to ...... i" ........ :-_.,,f ,.7:''--.',_7L,'5"--: "J ........,.'j..., _."'.i,illtAhcI each was i0_;L_itl,:d:'nd theil averaged, "l'iie /_-_tT_--..-;=-L;-7_-",_ L,-),,,%_ _t-,_-._o_ luaiit:action of cach in:.cct l_) cat;]l inediulll was al,:tl ob- ".................. - ' imsv,t r-_uAnts are particularly interesting - not so much l "-¢_._i v,_ozm4_l,/iu i 4._ Gt._ O.tbecause it is an insect with no ears - but becatLse onceilltul_t- liJllll O,i;tO'f_upset sdie attacks by bliiz_g with her powerful jaws(see pictures) and she .idso releases pheromones as wellas spray's for:hi: acid and other venom which adds totb.e discomfort ol the victun.Table I1: Sinothermg Time (in seconds)Cockroaches, on the other haM, creatures that havesurvived fbr perhaps 350 million years - through a/1 of MEDIA COCKROACHESnature's changes and :fl} ,..)fin.'mksattempts to eradicate .,_them, ate hcrc I_ stay because of the insects' ama/Jilg Trim 1 Trial 2 Avera1ability to dcvek_p rcsi,.t.,nce to in,.ectieides. Notwithstandingnewer tc,shniqucs - like using hydroprene Cooking -"24"-- 28 26which works by disiupting the roaches' reproductive Vinegar 44_ 9"7 70systeminsect hasandremainedthus actsinvincible.as a sort of birth control -, this KeroseneVaseline Hair Tonic20 20192019Alcohol 72 20 21An insect is considered smothered or suppressed the Mineral Oil 40 42 41moment it becomes limped or motionless. Baby Oil 20 25 22tiydrogen Peroxide Still alive after 600 second:Results Tap water Still ',.diveafter 600 seeo,,.l:As to smothering property, the following observa- Lignosporin 80 I 84 . _>2tions wet',' noted. (_1the dil-l'erent media selected, V:_se. Neosporln I 178 i 170 I 174Jine ilair'l',mk ln
Table I1: Smotheri_lg Thl_e (in seconds) cock.roaeh_ b_arne limped and fla0wed no grab Life................................. a._gnswhile the ants were immobilized after 28 secondsMEDIA ANTS and 24 seconds respectivdy. Following them i.scooking................................... oil whic!r immobilized the coe,kzoache_ in 26 secondsTrial I Trial 2 Average and tile ants in 34 seconds. Furthermore, both insectswcle not provoked at all in any of the 3 media. Therc-C_.king Oil 35 3'3 34 fete, because of their short smothering time, in additionVi_,cgax 91 47.0 255.5 to thek bein8readtly awailable and having no effect onKer,:,em: 24 20 22 the vestibular apparatus, any one of the three would beWelme ltai_ Tomc ?5 3t 28 a top choict fat a household solution which can beAlcoi_olMilt_r_ Oil3,q4032443542used tbr this kind of an emergency./daby (M 22 26 24 Alcohol and kerosene have a killing time compara-Hydrogen Peroxide Still alive a[ter 600 seconds tive to that of Vaseline llait Tonic, but their provocativeproperty, which could cause these in_,:ts to react ",rio.Tap Waterl_ign,,JsporinSti.l/alive after 600seconds9 ? ,3 72.5lently by biting further, in addition to their caloricNeusporin 185 145 I 165 eflbct which is very distressing, eliminate them fromWa_.sol 148......................................................79 / 113_.................. t........! the list of recommended ear solutions for this purpose.Water and hydrogen peroxide, on the other hand,should not be used as both media exhibited no smotheriJlgeffect.Of the different media used, cockroaches appearedto have been extremely provoked by kerosene and aloe- Therefore, when an insect is in the ear canal, an oily_,_ofOn the other hand, ants showed extreme provoca- substance, such as baby oil, Vaseline |-lair Tonic andtion in vinegar, kerosene and alcohol (see Table liD. cooking oil would be ideal to drop into tl_e ear canalto suppress first the intruder. Afterwldch, it can be'l'h¢ caloric effect of each substance was not tested removed by gentle irrigation or with an appropriate,._ it wotdd entail testing a human subject for the put-Wse, But on the bztsis of volatility, alcohol and keroforcep._,e are expected to cause dysequilibrium or temporary CommentIos_ of balance ;Is one of them (,ilcohol) has actually Extraction for animate foreign bodies from the eart_eenused tk)rtb.at purpose, canal carries a definite risk of additional trauma if theTable 111 l'mvt)cative Effect insect is not completely hnmobilized or di._abled. If adiflicult _0mt)val is attempted e_pecially without anes-MI.DIA Ct)('KII()A(JI.IES ANTS Ihcsia, the foreign body may be forced I]liOUgJl lh©tympanic membrane into the middle ear, resulting in aCookir t!.()d ....... conductive type of hearing loss and infection. StenosisVinegar _. + of the canal may also result following injury to the earKerosene + + canal wall, For these reasons, it has been suggested thatAlcohol + + further attempts at removal without, anesthesia beV:l.._c'line ltair T(mic -- discontinued._Mineral Oil - -- Once anesthesia is considered, however, the patientBaby ()il ..... need to be hospitalized thus increasing the cost of whatHydrogen Peroxide ....... initially appeared as a prima_y health care problem. InTap Water ..... time of economic crisis, mmecessary hospitalizationl.it__osporin ...... . should be avoided. The use of conmxon household reme-Neosporin ..... dies will make anesthesia and hospitalization _mneces-Waxsol ........ sary. Likewise, recourse to expensive otic solutions isDiscussionalso not needed as proven in this study, since all 3 oticdrops tested failed to compare with the 3 commonA good _ar solution for suppressing or immobilizing household items previously tested.Immure foreign bodies in the extemal ear canal under-_taadably should have the l_owing criteria:l. Readily available and cheap Summary2. Short smothering thne A study has been conducted to determine wkid_3. Cause no provocation among the corrm_on household remedies would be best4. No caloric effect suited to use as an eatdrop in case an insect crawls into5. Cause no itritati_m attd other complications the ear canal A total of 9 household items and 3 recall-From the result_ obt_)illed, it wt)uld be noted that cared eric drops were tested and the insects' responsesV,t_elmc!lair ['ollJc alld I_ahy oil are r;tsndouts. In an noted slid analyzed. Results r_,wealedthat ar_ oil), suba_'t;I._;Coi' 19.5 sec,.,l_d.'; _l_ld 22.5 seconds xespecltvely, stat_ce is best suited for tltis purpose.434
BIBLIOGRAPHY1. l)e Wee_e, DD. arid Saunders, W.H.: Textbook of(3_olaryngology, 6th t_id_ti,)n,tixe C.V. Mosley Comt)',my,St. l.oui:i, "I()r_ntt>, l._)ndL),, 1982.2. ,a.,lams, G.L., ct. _d., Bt)i,r's FumtaH)entals of Otolaryn_F)ltJg),,5th I dili_m, W B. Saunders Company,l)hil;tdelphia, L.uttdoli, 'I"_)ronto, 1978.3. I,I(,)Ildobler, B. _,i_,.lI)aw_on, J.l).:' The Wonderl,dlyDiverse Way._o1 I]_cAnt, National GeographicMagazine, June 1984, Vt)l. 165, No. 6, pp. 775-813.5. l'nriquez, Angel, M[). Verbal (?t)mrnunication.435
Tl_eh_- 2. HistOry of previous treatment with nofnud_,,orof oto.tk.M & Neck_dine or sodium bicarbonate nasal irrigation._:._y 3, Cooperative and promised to have regulartbllow-up.Ten _tknts were inclnded i_ this study. Their agesrant,.ed from 17 to 58. All were females.RI:'IINOL AND TEII,_ACYCI INE FOil As a routine, we began with thorcmgl2 cleaJising ofATROi'HIC IOIlNI'-I'ISthe ii_a.l cavity by washing, sectioning and removal ofcxust. Retmol and tetracycline ointment_ were mixed atl:l proportion. The resultant mixture was liberallyimpregnated into sterile nasal strips. Both nasal cavitiessvere then lightly packed. The patients were advised toBemabe S. Sing.,,on, Jr., M.I).* come back after 5 days. On follow.up, the nas',d packsCelso V. [Iretu, M.D.* were removed and the findin_ were recorded. TheRic'ardo l:"crnandeL, M.I).** whole procedure was then repeated. For patients whoRuz.anne Care, M.D.*** could not tolerate nasal packings, daily swabbing usinga cotton applicator was done. Treatment was discontfiauedwhen tile na_al m_cosa was foulad to be healthyhmking upon ex;mfirtation or if no cl_m'e irt the fetid_xlot or crusting were obtained after four packi,gs or't-Inlrod tier ion:m equivalent o f 20 days t reatme nt,Atlopic rhinitis is still one of the nlost disturbing"Ihe following clinical data were rt:corded:d_-asc to the patient aml a dilicmma to the otoiaryngo_ !. presence ofozena (fetid odor)k_g_t. Many patients with at,_ph.ic _hinitis come to the_.,tolary'ngoh_gi!_t with the hope that a cure or a lasting •2. disappearance ot persistence of crustingtehef ,a, 1._¢oblaim.d. _lt_t _ll_IJ]tud:ly, _!o entirely 3. dtange in color or fullnes_ of the naaai rnucosa_atisfa,:tory treatment has been developed. Frequent 4. numbel of applicants_a_ irrigations anti c
of ozena. After treatment, ozena was relieved in 8 lxt,- phic rkiattl_ Aside frt_mocgmlm_ d_odgement oftMtients a_d dirninizdled ia 2.nasal pack into the orophatyt'm, this procedure is rela.All of our patJems _ad czu_ti+_gprier to treatment, tively free of any complication. It is more acceptable,"l"ab_¢ill :q_owsthat after I.:eatzue_t, crusting was 1eliev- less inva$ive anti definitely less expenMve than the
T_ _'h_t. media as the single _rul tm#ctllin, and more effe.¢tl,m._ofO:o, }_d& Ncckthan the ingredients of the combination used zeparately(3).Pediazolel_tsalsobeen foundto be activein-vitroas weLl_sinvivo against Hemophilus hafluenzae resistantto ampicillin. (2){.)t_jecfivesA CI,INI(:AL TRIAl., (_i" A (,.'(JMIJINATION()['I RYTIIROMYt'IN l'.'l IIYI,SUC , ,(, INA_[E , : To cstablLsh tile efficacy of a combination of cry.AND SUI.I"JSOXA/O! 1'i ACETYL.IN tlu,mlycin ethylsucctnate and sulfisoxazol, acetyl(i'H__IAZOI.E) in the therapeutic management ofBACFERIAI.F1LIPINOOTIIISCtl II.DMEI)IARENIN bacterial otitlt media in rite pediatric age group by:1. determi.nitag the clinical respon_ after admii_trationoferythmmycin and sulfisoxazole.• 2. determining the sensitivity of the organi.masRi_rdo Fernandez, M.D. cultured from middle ear discharge to erythro.Romerico C. l)avid, M.D. mycin and sulf'tsoxazole.To establish the _fety of the drug combLuationwhen administered in the prescribed dosage to Filipinod_fldren by:htroduction 1. detemfining the effects On the blood pictureby comparing the complete blood count beforeMiddle ear infection i:_ one of the most corrunon and after therapy.debase cntity encountered by Ololaryngologists and 'pedntdcians alike (2). Normally, the middle ear corn- 2. detemxining the presence or absence of anyk_attment is considered steriie a_td its drainage is facfli- untoward reaction which may be atgibutablet,lted by a properly functi;mmg eustachian tube (6). to the administration of the drug.IMeclion war,in thi._ Jrea gone/ally results from inade-._ate draiuage with introduction of pathogens either Materials and Methodsof thtotJghtile through a eu_tachialh pertbrated e;Jzdru,u tube (;,s iu itJlt+_',ta++dingLIRTI) Cbulc¢ of subjectsThirty-five Filipino male/female children from oneMedical therapy is thercf'mc directed at resolving to twelve years old with bacterial utiti_ media with dis-_,!cttJ,_ with Ihc ur.e _,1al,lmq_ll,de antlbiolt¢,j alltl I,y charging ear, untlatetal/bllatelal, wlthuut surgical coln.facilitating drainage of' the middle eat with the use of plication; example, attic perforation, cholcsteatoma,,,'e,._ngc._tants,mucolytlc_, :mt_-i_ltIammatoty (>tic drops, ;rural polyp. Patient exclusion:and l_)_.,,ibly with _._,ticot,titaiit aur:tl irrigation arids.icliolling. Failure of therapy pumarily results from the 1.. Known hypersensitivity to Sulfa/Erythromycin_,r_mgch,oice of antibiotic or inadequate drainage of drugs.:h_'middle ear compartment. 2. History of any form of renal or hepatic fun,>The choice of appropriat,: antibiotic is dependent tion impairment.,,,nthe _cnsitivity of the organi:;ms frequeatly encounter- 3. }tistory of allergy or bronchial astluna,ed in i_ffectJtms of thi:_/_:lt_:rc.._illce astute otitL_ media,s most conun
, l ' ".......' ' Ithe milldle ear. The di_rharge_ then examined utilizing history ofllllrdllchltr_;the lbllowing steps: II. Acute Re_rrent Otitil Media - patients withacute exacerbation of an inactive Chronic Otitis Media;I_leil=.j. J""r,111. Subacute/Chionic Otitis Media .... patientiiwith middle ear discharge of more tlaan I trmt;th duri....... _.* ......... _ ..... , ,,,, ,_.t, [ il HI.J t Tahle I dmw:i tim relatio,i between the type of ret-, :.............. ......... " AImnsc nL_t,.tl,lhere to Pediazole js a higher acc,lrding percentage tel clinical el Fait-(hgod t) pc. AsClinicalcan b¢......... ,........... lesponse in the Acute Otitis Media group (AOM) aa,J..,..,:aa:';--_ ........... .__,_.,...., Acute P,ecurrcnt Otitis Media group (AROM). There ate.... 4/12 (33%) of Fair' clinical response atad 71'1.2{58_'(.;o-d clinical response in the AOM group; while hi theDrug Treatment, "l'hc do:,e el t'cdtazole was calcu- AROIvl group. 5/9 (55%) were fair it, response and 4/0rated based on the eryth:omycw_ ,component (50 mgjkg/ (44%) were Good in response to Pediazole. In the Chro-_/ay) or the sulfisbxazc_ie compol_cnt (150 mgJkg/day) nic Persistent grot, t:, the Poor clinical re,peruses wereIoa maximum of 6 gnx/dav. Pediazole was administered almost equal to the Fair and equal to the Gt×_d clinicalm equally divided dose:; four _imcs daily for 10 days. It responses.w_,_administmed w,itho',_ regard re)meals.The following appr(Jxm:ate d_sagc schedule as Table I. Frequency Distribution of Respon:;e Accordinl_recommended for PediaztAe v+a._tollowcd for convc- to Type of Otitis Media,lience :Clinical Responses TotalBody We, in Kg'< I.)_Jscevery 6 l'.outs Clinical T_'pe, Not tlealed Improved tleaicd No.of- ;tto)bed)' weight (Poor) (Fair) (f.;ood) Ca_l,"1( 18 lbs.) '_t.';p(2.b ml) A. Acute Otitis.Meida 1 4 ' 7 12lu 135 lbs.) 1 ts[;, (5 Itl}) Media24 (52 lbs.) l!,i )sp (7.b ml) n. Acute Recurrent 0 5 4 9Over 45 (over 100 lbs.) 2 tsp (10 ml) C. Subacute/(_ltronic 5 4 5 14At the discrelitm of tl;c illveatigator, local heat "leYl'at. 35h>_,d cold al_lllicati,m, olal d_:,_,lq..v!i!:mts, allalgeiic's ..............................................................................I,lr'tevt'i filial/or paill, hycl_ t'
ibis L_ th_ c_._e for many ¢+I the isolatod organism_own in tile _.able.TdbW!1: SF2qSITIVITY OF ISOL_ThD BA(_'ERIA TO PEDIAZOLECIJNICAt, BAUIERIA Fl(i,()t rl Nt'Y (;RAM SI}IJ.I_)XAZOLE ERY'I'HROMY('IN PFI)IA_*OI,I[I'Y_S I_)IAII.IJ O1. I>,_)IAIIt_N SLAIN S R ....... S ..... R ...... S........ R.......................................................... :L ............................................_Tt ITI_ i'.-,.n_pm,_ i .-, '2 .I 0 5 2 3orrrls 5, au_ :+ + I 2 ;t 0 3 0MEDIA P.nm-_ii_ 2 -.. 2 0 0 2 2 0t.,-l_.molyIic Slrep l + 0 I I 0 I 0E, cob i -- 1 0 0 I I 0ACUTER }...,(bEREft[ S, Auteus b + 4 2 3 3 5 Ior[ll$ P. acto_nusa 3 - I 2 0 3 1 2W.t,DIA B-Ilemolylic Strep 2 .t I I 2 0 2 0P a_rogtm_a . i0 - 7 ] 0 I0 7 3OtRONIC," S, aureus 1 + 1 0 I 0 I OOTI'TIS P. rettgeri 1 - O I O i 0 IIwgDIA P. ¢ulgari_ l --- 1 0 0 1 1 0KlebsicUa- 1 -- 1 0 O 1 I OAerobactert] _blc 3,Pelcelflag¢[_'e, lcentagePercentag,uNo. _,l "lypcs fOrganism o1' sensitive (>f he',de,d of cases withi'hn+c:'l I'yl)¢S ('ases .......... lso_J__!te,.d_ ........... otg:,nisms for cases in|prove|nentt)_ganisms Incidence each clinical (GOOD) (FAIR)group (.Based Response Response.- . ..... .....Acute Olms P. aeruginosa 5_,l,,dia S. aureus 3P, inirabilis 2on Table' 2)I 2 a-hemolytic 1 75% 58% 33%strep.E. coli 1Acute Re,'urrent S..aurcus 6C)titis Media 9 P. aeruginosa 3 72% 44% 56%B-hemolytic 2• , -..Ct,tumc/Subacute P. aerugii,osa 10strep. .............. - ..................................fHfli_ S. aureus I ,_teciia 14 P. mirabilis 1 73% 36% 29%t_. zettgeriIP. vulgaris IKlcbsiellaiAetol)agle,r 1°
Table3 shows tilec+mqmrksonof ActualFairand ponsesinvivo,Thish accomplished inTable3 where111Good Clinical response _,:_the predicted response based see that the correlation is inver_ly proportiorml to timon the _n.titivity pattert_ of'the o_t':misms. Based on the chronicity of the disease. The incomplete correlation:ietr,itivity pattern of Ihc o_++a,_i,mtisolated per clinical between the sensitivity test results and therapeutic effrtype, wc are able tu make predwtionx of the clinical ca_ in some of the patients in our study serves to remi_rcst_l.'.,,e. For cxatiq)h:, ill Iht, Acute Olitis Media group us that, in additi()n to variations m drug absorption, them(A(h\t) the totld i_,:zccJ£tac,,.,_[ sc_sitivc organl_an:; i_ ate multiple olher factors operatiJlg ill hlm_at_ infectit_rthe group is expected to be about 75%. In vivo we whirls cannot be reproduced in vitro studies. The actu_actually lutve abuut 33% fair clinical response wlfile numbers of bacteria infecting the host tissues cannot la58_, ttave good clinical resl+un_ to Pediazole theiapy, known and organians isolated _tmy be mere cont,,m.,'1he expected sensitMty ot the organisms for the Acute nants. The complexity of the tissue and body fluid_;Recurrent OSiris Media group (ARt)M) and Chronic/ which serve as growtr_ medium in vivo cannot be accu-5ub_cute Otitis Media gruup (CSOM) are almost the rately teproduc.ed in vitro. The inlluence of the Immuresam,: as the AOM group. As far as the good clinical responses of the host cannot be introduced artificially. ItrCSl:x)nse is concer'z_ed, it nan be _tuted tl_tt the per- is therefore apparent that antibiotic sensitivity studi_centage of Good .;h,_.icA ru:ip_ttsc Is inversely related as performed in hospital bacteriology laboratories, mayto the duration of the disea.:e process; e.g. the more not be entkely reliable in predicting el't_cacy of a theft+chromic the case, the le:,s [,ercci_tage of good response, pectic regimen in any given patient and must be interthuswhile there J:;58',;; (;,_od clinical response in tile preted merely as helpful hints.AOM, fltere is c_I_12,.' 44jb and 36% Good Clinical res.ponse in the AROM und CI'OM groups respectively.This ist he pattern ohm.erred rt:gardless of the type of Pharmacologyorgar_ismsisolated. The antibacterial mode of action of Pediazole hbased on the inhibition of bacterial protein synthesis b).erythromycin on the one hand, and the _ompetitinDisctlssion inhibition of bacterial synthesis of folic acid from pare.+[he evaluation of antibiotic therapy for otitis aminobenzoic acid (PABA) by sulfisoxazole on thtmedia is diflicult beca_se of the high rate of sponta- other. Previous preparations of sulfonamides involvedneons recovery. Heller evaluated 588 cases of otitis various combinations with trimethoprim, a known i.nhi.media and note_l a Sl+Unta_eous resolution in 5tY,t_ of bitor of dihydrofolic acid reducta:;e, resulting in ttile C:lS_..s(/). In a +n,,tc lucent study with a smaller sequential blocking of bacterial synthc_;is of purmeta_number of patients, spolllallC, It is possible toco_:_pzte their sensitivities in vitro with the clinical res-441
DIAGRAM OF THE META BOLIC STEPS WHICH ILLUSTRATE SITES OF ACTIONoF SULI:ONAMI DES, t 'FRI M ETHOPRIM, AND ERYTH ROMYCIN' 1substrate + PABA _, FOLIC ACID I_ "/olic rcduct_e.. .__, DIHYDROFOLICACIDSr J1.I.()NAMIDLI ;¢mq>etttlve irdu bilioJi)dihydto futieacidreductas¢J TETRAHYDROFO LICTR IMI'TI {Ot'R IMAC[ D(selective inhibition uf .......bacterial dihydrofolic acid i "f_rcducta.se/./_'-J.,4_o.F()RMYI..-TI-/I]RA i15' I.)R(JF( )1.I(' AC'ID?URINESDNA, RNA ...... _, MFTHIONYL-tRNA :_ FORMYL.METHIONYI.,tRNA30S component ofbacterial ribosome ..... ,>nRNA w/initiatingco,Ion (AUG) forprotein synthesksGTP- - "x /50 S component ofbacterial ribosome : • ..... iERYTHROMYCIN " -(biqds to the 50 S component. itthibiting sub:',Cquent stepsof protein synthesis• " 70 S bacterialribosomePill 1'1'1,INS / transpeptldatlon_
)STRUCTURALFORMULAh"PARAAMINtJI_IiNZOICACID(i'ABA)BASICRINGSTRUCTURE0 F SULFONAMIDEi " CO_HI h II0 1 p.AMINO.BENZOATEst )BSTI'I'UT[-D I 1I'I'I-I.UDINE I 1FOLICACIDGLUTAMATEc_ C)i5 )_' 'chl } _4'!!5•0 0o_ERYTIIROMYCINqt_c_)USLJLFISOXAZOIJE
Withtheadventof Pediazo]e, a new drugcombina. 4. ]'lowtrd, J.E.etal.OtitisMedia of Infancyandtiu,a wiih a blunder spectrum of aJitibiolic activity is Early Childhood -.- A Double-Blind Study of Fourt;:p_eilt. Tile combi,ed atlior_ t_f inhibition of bacterial Treatment Regimens. Am. I. Dis. Child, t30:965.l_r_ther, is uf' pIotein aJ_d I_NA in a si_gle therapeutic 970, Sept. 1976.rr_,i.'_lelt would lavoi ll_c t)tllikclkhood uf the ernergei'lce 5. Rodriguez, W.j. Erythromycin Sulfisoxazole --of;ttty tc:_istantbacterial .._tr,dttsthtuul_q_tw,ltation.Their Use in Acute Otitis Media Caused by Ampi.B_,tit [:irythtomycin ethyl_uccinate and Sultisoxa+ cillin-Reiatant ttaernophilm lnfluenzae, lnterscience.o',e acety] are rcadii_' _bsurbed in the GIT' and have a Conference on Anti-Microbial Agents and Chemo-',,¢_ylow iucideace of u_tua'.vard,:tloots, less than O.1% therapy, Nov. 3-4, Chicago, 1981.ut patl,:t_ts receiving Sulfi_,).x:a/,._lesuffer serious toxic iS. Riding, K.H. and Bluestone, C.D., Michael, R.H.,_t,actions (Yow, 1953). Bucau.,,e of its relatively high ('artekin E. 'I., Doyle, W.J. and Poxiviak, C.S.t,.lubili:y in the urine, tl._: ri_k of' vnuria and renal Microbiology of Recurrent and Chronic Otitist._.xtcit)is low as computed to the older sullbnamides. Media with Effusion. J. Ped. 93:5 739.743, Nov.[._vthrulnycin ethylsuccitmtc ,_r: ti_e other hand is con- 1978._ct:tratcd in the liver ar,d excretud in the active form intm bile. l'lypersen'dti'dty reactxtms are infrequent and 7. Krause, P.J., Ownes, N.J., Nighting-,de,CH.,Klimek,.bsappe;.ushortly after t]tetapy b;stopped. J.J., l,ehmann, W,B. a_ld Quintiliani, R. Penetration• of Amoxicillin, Cefaclor, Erythromycin+Sulfisoxa.Asi,le from their paticn_ t,JlerabiJity, both drugs zole and Trimethoprim.Sulfamettxoxazole illtO the,,mplcment e;u.h uth,:l in ',c_m._,,f budily fluid distri+ b,hddle Ear Fluid of Patients with Chrul_ic Serousbillion, l'.rythtomycm dtflu..c._ tt'adll.'.'r into intracellular Otitis Media. J. Infec. Dis. 145:6 June 1982.i]utds. All tissues except the bJ:tm contain higher collct.tltrationslhan m the bldg.)d.:rod tile drug persists tbr _; Liu, Y.S,, l__u, D.J., lang, R.W. and Birck, H.G.a,llle time in the tizsucs aftur it _s at! longer demonstra- Chronic Middle Ear Effusions. Arch. Otolaryn 101t_tem the circulation (serut_ h,df hie 1.5 hours). Sulfi- May 1975._xazole t_lt tile uther h;lnd is distri0utetl maudy in the 9. Zinsser. Microbiology. Edited by JokJik, Wolfgang,cxt_':tcellular fluid compartment and its serum half life K. Willett Hilda P, Anms, D. Bernard. Copyrighttsb houls+ (9, 10) 1980 Prcntice-HaU Inc., N.Y. 1980.Conclusion • l O. The Pharmacol_igcal Bans of Therapeutics. 6th EditionEditors: Gillman, Alfred G., Goodman, louisEvaluation of the clinical response of the 35 subjects S, Gillman, Alfred. MacMillan Publislring Co. Inc.,indicates a good level uf effectivity of Pediazole in the N.Y., N.Y. Copyright 1980.m_,agement of Bacterial t_titi., Media specifically m._ute processes. Sig_fificant reduction of associatedm,:nbidity such as _hiniti_, _inusitiz, pharyngitis, andtunsillitis is also noted after therapy.Organisn_ cultured from middle ear discharge maynot be representt_,tive of the true path%et_ and furtherstudiesu_ isolation techniques may be indicated.Evalnation of the toxicity uf the drug combinationindi,_ttes it is well tolerated araoug Filipino children.No adverse reactions were rioted in any of the subjects_ld blood picture studies reveal only a slight decreaseto Wl_C¢_)urltwhich nxay be explained by tile resolution_lter tlielapy,IH_3LIOG R AI'H YI. Sell, S.H., Wilson, D., Stanm, J.M. Treatment ofOtiti:s Meida Caused by llaemol)hilus ]nfluenza¢:l.:valu:ttion 'of Three Aotimicrobial Regimens.Southern Med. J., 71(12): 14q3d497, 1978..' Schwartz, R., etal+ The lncieasing Incidence ofAmpicilain-Resistant tlaernophih*s btfluenzae. .J A-MA 239(4):.320-323, 10%.3..ltowie, tiM. and Ploussard,J.ll. Efl]cacy of FixedCombination Antibiotics Versus Separat¢ Componentsin Otitis Media, ('li_lical Pediatrics, 11(4):_t). +,_14,1972.444
Scientific-Symposiumon'"INTERESTING CASES IN OTOLARYNGOLOGY"held on August 24, 1984 at theHyatt Regency Hotel445
_ 't,._rof I,hit ()t_.i.on. There was no change tn the vision until five years_k'_d& Neck later, when the left eye gut infected arid unff_rtunately,:r_,x_y becanre totaUy blind. Tile right eye, however, still haslight perception. And since this is the ordy functionaleye, Efforts were made to make it a bit more functional.lie was then scheduled for kcratoplasty of the righteye. But prior it) surgery, the ophthahnologL_t wotdd¢1I?ARS FROM '1tie PAROTII)* ward a constant source of tears to batlle the eye. Teartuoduction has been absent in this patient because of" damage to the lacrimal giant} by the rnur]atic acid. If_cc,mslruction were to succeed, then, SOlnething must be&n,c to ensure lubrication of the eye. Methods rnention.cd above were evaluated but were later discarded sinceJosefi,m G. Hermlndez, M. 1).** tliey were felt inadequate.'C,Jl M. Vicente, M.I.).** And so, tie was referred to us to put an end to thisMariano Caparas. M. 1). *** pl edicament.On admission, pertinent physical examination__-cnlcredon the right eye whereto a con_2mner wasn _tcd Cornea appeared keratiaaized aJid fornix was shal..low. "lhere were conjunctual adhesions noted. There wasWhen tile lacrimal t:land i___Jisea:_cdor traumatized light perception on the right eye but on the left eye itaf_! coi_:,equentiy ce,a:::e,:it_: function of lubricating the was absent. There was likewise no tear production. Theq,,¢, how will you as a doct,.,r come to the rescue of resr of ENT findings were grossly normal. The[e was no•,out he!ple.',._patient'?par,_id swelling, no buccal mueosa lesitm.Xer_q_hthalJnia or dry eye has been a troublesome A natural and physiologic alternative to tears fromi_ease ::il_Cet_me hrlmemoria!. It ks u.sually caused by tim lacdnlal gland is parotid secretion. The constituents•r,_chonla, surgical injury or trauma to the lacrimal of Ihe two secretions which resemble each other and thejaml, Bell's palsy and 7th lierw: paralysL,< p:oximity of the two gJands are of great significance.Several methods t-rovebeeli suggested to prevent an Hent:e, we did Stenscn's duct transposition to the con-:s.e Jal dr)ing of tit,: eyes. The ophthahrologists have .iuctival sac, patterned alter that method done by James,:1,:,.1sl _.,.c,,Ibhtcka!.t: _)f the l)lmCta lacrimalis, tatmtirep_ocetlurc done iSdescribed a_ follows:I:. Benr)ett and Robert Chase. Under general anesthesia,,atd_y,rod high doses ,_l' Vltan,i!l A. But many rccolllw,rtdth _t their patients balhc their e/es using artificialie,,_. [. Location of the Parotid duct.All of these may be ,,f help bul they are largely The coulse of the parotid duct r_n along aloftbruited,and hence unsucce.,sful in preventing, tile coin- , ZUl_talhue from the ala of the nose to the earp!_,ationsof total xerophthahnia,lobule. A vertical line from the lateral canthus"l'h_:refore, a mo_e dcsiralde method, we have of tile eye bisects the point where the parotid:iways desired sornethi,_g natural, so,nething which duct curves deep at the anterior border of the,Jeliveraadequate flow of secrctitm for lubrication alltd masseter muscle to enter the ntouth opposite,: st of all, something which is physiologic,•tile second upper molar. This point of bisectionbetween the vertical and horizontal lines wasOtolaryngologists have always been the ophthalmo- marked on lhe skill.l,a_;_st',_partneL And in this kind'of sit',_ation, our expertassislalwe is itrdeed net:tied. II. Identification and Dilation of St,enscrFs Duct'l'he punctum of the Stensen's duct was identi-Wc are prescrating here p_tticnt, whonl we ofleredfled and dilated with a lacrimal probe.this kiJld of hettY, lie is G.I-., 40, male, flom Cebu Ill. Insertion of the Polyethelenc Tubetit_ who _even years _,g
the direction ,_f St_mcn's duct orifice, it was because of this infection. We h_cve to reintroduce athen tubed over the polyethelene previously longerpolyethylenetube from the .conjunctiva[ ticinserted. ThJs w_s done using multiple inter- opening bite the duct and let it stay there to mainta_rupted 5-0 dcxon suturea,its patency. This has solved the stenosis and the parotklVI. lm'i.,don of _,kittel t'b¢:ek secretion continued to come out to bathe the eye.At the ,ta_k prt:_ou'..ly irutde (Step I). a line A third problem vocalized by tire patient is thewas dt'awa _l:,n,_versely from aalterior to pus excessive secretion during meals. To _lve this roblem,eerier for a dist.mcc of two cm. in the place as various authors have recommended sectioning of thethe imagln:i;y iiac htma the Ma of lhe nose to tympanic plexus near the promontory of the middlethe ear lobutc,ear and alsotmcti0nin8 of the chorda ty_npani, It is aMsuggested ttiat forming a shunt between the conjunctinAfter the bu_;cal Inuca__sa WaS reached, the and the maxill_,ry antrum. Hewers:r, we did notattemptrnouthduct c._ificc.was enteredThus theat theexternallevel ofandStencil'sinternalto do these to our patient.hicisiom we_e),fi,icd.We referred back our patient to the ophthalmologixtsnow with sontethmg to keep his eye wet. We have doneVII. kxteriori_zri,m of the |'arotid Duetour pan, and the second big step to lag)at now depcn_The I:;_,¢_tid(]tt_l with the tube extension .ft,n the eye specialists. This made thitig_ a little brighter,the b_Lt:c;dm_;¢,._ wa'., brtmght out throughthe cheek ir_cisi,Jit,a big first step in the dado_ess.VIII. I)¢vehlpmcnt of Subcutaneous Tunnel to the Discus:,;ionInfero-latcral col-clericThis w_ devcl,:,pcd from the infero.lateraJ con- This is a story of a man, one of whose problerraja_tctiv_l _.ul-do.-sac:,bout tcm. from the later_al was the lack of lubricatioti to his only functioning eye.canthus thro,_gixthe cheek h_eision, i[is dilemma parallels that of somebody.with trachorraor Bell's paJsy or anybody with xerophthalmia. FkIX. Parotid DuctTrimsfer wanted very much to see well but before sight, i,A 3..0 black silk suture was placed at the distal improved, there :_hould be a preltmina_7 procedure tolip ofth¢ parotid duct with its tube extenskm, be done. And so by doing a parotid duct transfer, tl_Using a blunt curved clau'np, this part was search for something natural, sonrething, phytiologxtheeaded through the subcutaneous tunnel to and something adequate was accompHshed.the inlerim conjunCtival cul-de-sac at the lateralcarlthtt:, _2t'tb,:cyc. This was sutured to the con- It isnear physiologic because of theresemblancejuctiva. Multq,le interrupted ophtltalmic 6-0 between lacrimal and parotid secrcti_ms. A physico.chenffc',d tabulation of the constituent._ of _acrimal _suturc_ were applied,parotid secretions is presented. The pH, eletrolyte, iota2X. Closure of ln/raora_ de{eta, solid and osmotic concentrations are about the san_.3-0 chrc,mic catgut suttne.', was used Both contain lysozyme arid aretraaspare_at. The m_r,XI. Polyethylene tubing _u_choredto skin difference is the presence of ptyalin inparotid secretionUsing 3-0 black silk sutures. Ptyalin is a digestive enzyme which has been known tocause no deleterious effect on the eye.Bulky dressing was applied Patient was placed onantibiotic_ (Ampiclox - 500 nagQlD). Chloroophthalmic It Ls natural and hence no harmful chertffcal get_oimment was applied three times a day. Daily cleaning into your eyes, as when you use artificfid tears. It is adt_of wound ,_ere dot_c. _utttrcs were removed after 5 days. quite becau_ enough secretions a_e c,btaincd day in an_Polyethdcne tribe was rctuovei5 one week after with day out.clear secretion nt_tcd c_nmng out._ff the orifice. Pre-operative evaluation of patie:_ts undergoing IhaHowever, there were some problenx5 encountered procedure il_clude insuring a normal flow of saliva fruitpostoperatively,the parotid gland.First, there was the impending stenosis. After the ConclusionP.E.tube was removed on the 7th day, the orifice wasnoted to be impinged by the conformer placed on the The problem of xerophttv, dmia cart now be hurdlt_patient's eye. Hence, little secretion would come out by this simple technique of parotid duct transfer. "I_]from it. We have to reposition the contbrmer and tein. end result overcomes all the inadequacies previous te_niques have shown. Patients with Bell's pal_y or w_tttroduce a polyethylet_e tube to maintain its patency, facial nerve paralysis can bc greatly t,.elpcd. And abot_Second, there was the development of an infection, our patient, he is ready for a more promising surger)By the 10th post.oper'atwe day, yellowish exudate was " But whether the next step will be successful or not, tn,>ted to come _-,ult._flhe check incision. Culture study is notwhat makes tiffs significant. It is the fact that, t:of the (lis,:hart,_' _cvealcd :Iogrowth. (;rain st:tin was tire patient, we have brought him nearer to light.abe negative. We slotted to I)ala,:in and the itffectionw;_sc.ontl'_lled. But the duct seemed to develop _tcnosis447-
STC-Nf_N'._• PUtT\448
,,-- X.I/12. The very first local case0II. Identification and Dilatiun o[Stensen's DuctIll. InscltioaofthepolycthylenctubeIV. lla_vesting ofbuccal mucosa ak>nl_,the di;ectita!!' 13. I. Location of the parotid duet,'of the parotid ductV, l-lcvation and 'Fubiuk,Vl. Incision of skin of cheek• VIL Exteriorization of the Pa_otid DuctI_ _ VIII. Development of Subcuta,]eou_ 'Tunnel to the"-"-" fr- ,tnfeto-lateral cul-de-sacIX. Pamtid Duct TransferX, Closure ofltntaoral DefectXI. Polyethylene tubing anchored to skin,? )' 14.AntibioticsChloroBulky dressingOptha.lmicappliedOmtn)ent, Daily Cleaning of woundP-E tube removed after one w,.'ekt ,. Sutu,-_s removed after 5 daysX449
loutof :_ v)_il 0_,_,,for 2 weeks. Two week._ postoperatively, a dh'ect latyn._#a._ _,..,k goscopy w_ done to assess the status of the "Neo-:,.#?ty larynx." The right true cord was mobile but the glotticchink was only 10nu'n wide. The neo-cord was noted tobe edematous. On the 14th post-operative day, thepatient was decannulated and was able to swallow clearliquids. The nasogastric tube was removed and the pa-AN AH'ERNAJIVI.( GLO'Iq'IC Ticnt was started on so[t diet. By then, he was able toperf(nm maJ,euver such as valsalva and cough withRI(CONSI'RUCI'I()N I:OLI.OWING lunited phonation which improved upon discharge.HEMILA.RYN(;I-.(_.;TOMY* Solids were likewise tt)lerated. On the 16th postoperativeday the patient was discharge.l)r. Jesse C. l:lalt(Jaad(,* Operative Techniquel)r. Rizalino F. f:elarca** A tracheostomy is done under local anesthesial)r. Teodoro P. Lhun;mzares*** ,rod an endotracheal tube is hlserted for purposes ofl)r. Remigio 1. JaJ"in**" general anesthesia.A horm)ntal incision is made midway between theih) mid notch and the upper border of tl_e cricoid cartilage.The incision is extended laterally on either sidesltltro(luclion It) the anterior b,.,rders of the stemocleidc:.:mastoidmuscle. A subplatysmal flap is raised to the level of theIn ],g76 the first ve)tical .hcmilatyngectomy was hycid bone above and to the lower border of the cricoid_rformed by' Biliroth. l=tter, w,t,difk:ations were done below. The strap muscles are retracted laterally to expose_,_{;luck I',_,!e,.)1_ lltod_ficatk)ns in 1912 aml tlatuanl wc_¢ de:,_.ribcd in 1930. Since literature. then multi- In the thyroid cartilage. A perichondrial flap is raised from avc_tical incisi-z, made on the right hcmithyroid 3n|m:ia ti,_'.w,mt_dJ/icatitm::; the major i_lt)l)lcm was on the • I.)cyt>mlthe IrlidportitJn. The anterior edge of the flap ist._rwrrati,.>n ol laITngcal tt)n:.tlt)u foUowing the proce- continued posteriorly up to 3ram from the posteriorc,,re, tlo_'cver, it should )c emphasized lhat the extirpa- border of the left hemithyroid. An anterolateral pharynti_eprocedure must not bc c_)rnpromised by the anlici- gotomy is performed on the side of the lesion and ex-[.._!ed)ec,.)nstruction. tended medially through the thyrohyoid membrane. Agood view of the glottis and the cord lesion is obtainedA Case I,_el)ortfmHi above. With a Stryker saw, tire laryngopharyngo.1, October 1()83, a 62 ve,zs old, male, Filipino tomy is continued' thrdugh the thyroid cartilage 3mm_,:L_admitted at UERM-tl foz an l l.month history bey,)nd the midline anteriorly, tltrough tile cricothyroid.f progressive hoarse:_e';s. There was no associated membrane inferiorly and 3ram fi-om the posteri(n border_:@lagia Itc had a smoking,,,histoD' of 20-pack years.of tile thyroid ala on the involved side.tr.,,,,d exal_fination sho_ved ,'. leR cordal lesion. "_here The excised specimen includes the left hemithyroid_ r_o palpable neck node. Laryngogram showed cartilage with a 3ram margin of the contralateral air,_._rr@ottic arid subgiottic extension,'; ¢_1"the mass. arytenoid, left true vocal cord with 3ram margb_ of theDr:cot la,yngoscopy revealed a 5turn. cauliflower- ccnt_alateral cord, vocal process, false cord and a 5ramk,.,, g_owth involving the left antermr !/3 of the true cuff of the cricoid cartilage. No resection is done on the_,
the supel_ot and inferior edges are also apptoximaiod TABLE 11to complete the teco_st_ucticm. Anesthesia is lightenedto slightly awaken the patient,, Endoscopy is done to Five-year Survival by 1972 TNM Classification:assess the recor,structed laryrt×. The glottic chink was The American loint Committee for Cancer Stagingadequate a_ld tht' +il',httruc vocal cord was mobile.1061 cases ofglottic origitlThe recomtxucttve i>_,)cedu[e is continued by 522 ca.se_ofsutrgraglottic originappioxinrlatillg the ._,trapJllt)_clcsmedially, The wourtd 19 cases ofsaibglottic originis c2o_::din Iayer_aad _ll ailv,'ay ksinsured via a ttacheos- 1 case of uaknown origintomy tube. Penrose dlaills ale m_ted and exteriorized ...........through the lateral as;_e_t of the horizontal incision. Total 1632 casesLight compre_siori bandages are applied.I)i._cu_Mon TUMOR RADIATION AND SURGICAL SURGERYSALVAGEAdequate tumor removal and improved voice pre ..............................................................ser_-ation were our pri_ta.ry goals in the choice of a surgi-GLO'I'TICcial procedure, ltere, pr_.-_Jperativeevaluation and endos. TI 86% 65%cop)' wer_ very essential. "['hc choice of our surgical "I"2 55% 69%procedure has sati:;13,:d the i')82 indications for |iemi- I'3 29% 55%laryl_gectomy set by M_hr, cl ,,1.(I'aMe 1). "1"4 14% 35%l+he five.year ,_tltviv.d uatr_ tm 1061 caSeSofgloltic .............................. '..........................................................carcinoma as tep,,tcd by the A;:,2rican Joint Comitt_efor Cancer StagiHg, t'mi,h_ltud m I')72, showed better TABLE 1IIresults ill favut with :_ttg_:ty. ("l'ab!¢ ll) In a separate 57 cases of Laryngeal Carcittomarepoxt, .M°hr et. al., !;bowed promising survival rates All had Squamous cell carcinomaia 57 cases of hcmilaryngectumi'rs done in T1 through All underwent hemilaryngectomy"1"3 laryngeal ca_'cin(mka.s. (]'able Ill). These reports 25 TI Lesions : 3-,5-,lO-year survival rate = i00%strcrlgthened t)tJr _:huice t)!' I!emilaryngectomy as thesm,,ical procedure ,.)fchoice. : average survival in years -- 6.627 T2 Lesions : 3-year adjusted survival rate = I00_TABH! 1 : 5-year rate = 94.1% ':lO-year r_te = 84%1982 Indi,:atiol_s fur Ilemilaryngectomy : average survival in yeats = 5.485 "1'3l.,sions : 3-,5-,lO-year adjusted1. Tl lesions; especially for irradiation fail- survival rate = 100%ures, irradiation refusals and early age of : average survival in years = 8.4diagnosis (4-0years old or less)2. T2 glottic le._ions (may have impaired cord The laryngoplasty done in this case ks actually amobility) with the following anatomic modification of the procedure presented by Bailey ialimits: 1974. ltis procedure utilized a bipedicle sternohyoida. to one third of the opposite cord muscle flap with a laryngeal stent. Ours used a fullthickness sternohyoid muscle to reline the resectedb. to midveatricle larytot and to create a neo-cord. The modified proce.c. to 5ram sub[,,lottic extension posterior- dure was in effect simpler in that it only utilized nlysingle pedicle muscle flap.d. to I()mm suhgh)ttic ¢g|¢llStOla allteriorlvComparison of the Bailey Procedure with the• Modified Bailey Proceduree+ the entire hem|thyroid cartilage to1 cm beyond the midlme and up to Bailey Procedure Modi'flcd Bailey Procedurebut not more than the upper one halfof the il-;ilateral crib:old 1. Bipedicle sterno+ 1, Single pedicle sternohyoidhyoid muscle flap muscle flap3. T3 gluttic lesions with anatomic limits asabow: with fixation by bulk.or muscle in- 2. Laryngeal stent 2. No stent usedvasion, may be perlormed on irradiation usedfailures. 3. .Midline thyrotomy "3. Hemithyrectomy4. Double vascular 4. Single vascular supplysupply for the Ibr the muscle flapmuscle flap(inferior only).451
(superiorandBIBLIOGRAPHYilfferior) I. B_y, Byron J.,Glottic Recomtruction AfterMucosal lining for 5. N(_mucosal lining Hemilaryngectomy: Bipedicle Muscle F'lap Laryngotileflap plasty, Laryngo.mope: 85:960-977, i975.t, l.arnitcd resection (;, Wider re_ection ' 2. Biller, l-tugh F, and Luonte, Fraalk E., Reconstruct.ion of the Larynx Following Vertical Partial Laryn.,kdva.ia_cx of tile Modilicd I_lailcyProcedure over the gectomy, Otolaryngologic Clb_ics t)fNt)rth America:italic) l'rucedute 12:761-766, 1979,1 SmlplerProcedu[e --.o urmecc,s_ty splitting of 3. Blaugrund, Stanley M. and Kurland, Stephen R,,(lkusteu,ohyoid muscle Replacement of the Arytenoid l:oUowiaag Verticalt_():nuco_al lining needed Hetnilaryngectomy,1975.Laryngoscope: 85:935.941,.o -tcnta required4. Dedo, Herbert H,, A Yectmique for Vertical Ilemi-2_ _iasytailormg_t'thc Neo.urd lo fit the glotticdefect lary_gectomy to Prevent Stenosis and Aspisa_.ion,3. (Jives more bull,: to tire tccor_r>tructed Neocord since Laryngoscope: 85:978-984, 1975.it utilizes the full thickncg sternuhyc_id muscle, 5. Ennuyer, A. and Bataini_ PI, Iasyngeal Carcinoma,+. "fheotetically, there is lcs:;.:r bulk shriatkage of the Laryngoscope: 84:1476, 1975,Ncota)rdaRerradiatior_ thcJapy, 6, Lee, K.J., Editor, E:,sential Otolaryngology, 2nd5. Injection ofTello,l wdl t)c' tile/t,_ _,uccessful because Ed.: 312.314, 1977.the Ncocord is bulkier and debaser. 7. Mohr, Rose M,, et. al., Vertico-Frontolater'd Laryn-•_ Obviates the uxme(e_._ar', ,mmpt,lation of the hypo- gectomy, Archives of Otolary'ngology: 109:384.pt_aryngeal-pyriform sinus ;nuct_sa, hence discgura+ 395, 1983,giJ_ggranulation tissue arid cicatrix formation thus, 8. Quia'm, Harold J.,Free Muscle Transplant Methodpreventing glottic steer(isis, of Glottic Reconstruction After Hemilaryngectomy,7, _ider tietd of tc_ectiu'r_ Laryngoscope: 85:985-986, 1975,One of the chief complication following verticalhtmJl_.,Tngectomy is aspiration, This arises when there is,radequale replacement ()f the w_lume removed, Re-8a_emc,t caJl be tl(:l_e i_ ,_,cv(,r31way_;: Sonl has usedi._ces of thyloid cartilagr t. 11)carea where the aryte-_td _ ;,tx,t)ut this st_tmks cun:,_derabIy al_d is vulnerable:0 infection al'let a course tH" _,_diation therapy, Dedo_s used free fat and fascia g_;_ttplaced under a mucosal_,b,anccment flap, however, the major difficulty was onestunation of the volume required e_ecially since_trophy would occur_ Our p_ocedure used a full thick-•t_s slernohyoid m_cle llap. This muscle graft has,_heorcticaUylesser bulk sr_,riukage properties, compared;u the lo()se cartilages and volume estimation wil not.,_much of a problem since atrophy is not very signifi-._'lt._mlltaryThe initial §uccess of flUS +eport on a modified_u-ynguplastyhas showed technical sitnplicity and fune-,).realefficiency without comprornise on tumor extir.;atlon, Furthermore, the technique has maximized the/,,)tol>erativelaryngeal fu,ction in teNm of satisfactory_.mation, respiration and d(:glutition. Postoperative_.)ttic ster,;,sis and aspiratiun were not observed in thereported. This paper does not end here, but this is?.,r$tart of what might be ,mother milestone in the_:.aalsof 1.at:neology •452
Th,"Phil. }listory and Present Illness. Five years FIA, tl_]o,,rorOto,patient first noted a 1.5 x 1 x 1cm on the rig.)nmandibb}lea,t& Neck described as hard, fixed, non-tender arid progretaibb/Su;-_ryerdmging.One anti a half years PTA, the mass measur_laround 9 cm in its greatest diatne_er. She consulted ata private hospital where the mass was "excised en bloc"AMELOBLAS'IOMA ARISING FROM A and read as "dentigeous cyst:' on histopathologic rtpo_DENJI(,I_R()US CYST* of the tissues, bones and molar tood_ removed, bated otthe "dense fibrous connective tissue lined by non-kertti.niztng stratified squmnou,s epithelium." ,She war dischargedapparently well, but a mo_tth later, the n'amrecurred and gradually increased to about 6 cm tn _twidest diameter.Jacob S. Matubis, M.D.**Jo_fino G. Hernandez, M.D.** Thus, 10 months FFA, _le was re-admitted inAdoni.,, B. Jilt;trio, _{.1) ,at $:1111¢ hospital where an "excision anti curettage" of thema_ was done. }listopathologic leading of the eyucapsule and bones taken during the operation showe,1"dentigerous cyst" at_d disclosed "den_ fibrousnectict tissue lined partly by single columnar epithghua_Introduction and partly by metaplastic squamous epithelium." Shtwas discharged without eomplications after 18 days, bu:Ar,_eloblaatoma is by far. the most common and about a month post-op, the ma_ re,:urred and rapi_most important of .allod,mtogenic tumors, t Its invasive- grew in size, so she Finallyconsulted at ou,' OPD.heSS and high recurren, e rate have intluenced some Physical Examinatkm. Pertinent Fmding wa_ tauthors to name il as a "kxstologically benign but clinicall)'rtralignam" .tesion. tt may arise from the remnants12 x 10 x 6 cm right mandibular nms'_,fixed, non-tendeof dental lamina, basal layer ¢)f oral mucous membrane, with ping..poag ball consistency, bulging ir_to the gin_-_area and displacing the pre-molar and molar reef2tht_enamel organ, and rarely, from a dentigerous cyst. medially.Batsakis: stq_pt_rts the same view, stating that it Radiographi_ Ex-,nination. X-ray _1" the n_an(libk,rely ,arely a_:,_:s fr,,;,1 a tlcntit_:l_,tJS _:yst, despite it- showed a huge tissue mats density in the right hemi-._t._ptJrts to the co_ttraty. It ha,_I_ee,l tncntioned by Robin- dible with absence c,f the body. There were incomple.,s,n and Maftiz_ez3 ll;at illf, t:)O_ll;.tstollra arising from a ""der_tigcrous cy:_t is otdy defensil_le when it' cart be septations mandibular inrenmants. the peripheral No abnormal portions calcificatitms of the right he_ _,'t:tdemonstrated that a _,on,neoplastic cyst existed priorto the appearance of a_eloblastotua or when both the noted. Findir_gs consistent with _mxeloblastorna.lhtmg epitAelium seet_ notm_d.l_, in odontogenic non- . Histopathology slides taken on the first two op¢_neoplastic cysts and an:elobla:aoma epithelium are tions were _ccured fr_m the first hospital and revie.a_l:n,:_entside by side. A similar reading of"dentigerous cyst" w_ made by t_We are prese;',ting o,_e such rare case, serving a pathologist.notice that recurrent dcr_tiger_,u:;cyst may indicate the The patient was presented at a Grand Rounds Cot.prc_nce of amelobla._t,lmaa warranting a nro_e radical ference and the general concensu_ reached was that thsurgery for adequate Iteatm(.',nt, Furthermore, serial clinical course of the mass was more suggestive of amt__:ti¢,ns of all tissues rct,oved should be examiued blastoma, tiros a tno_e readi.cal st,r[,ical procedure _microscopically t__get a cormcot diagnosis, and lastly, decided on, a right hemi-mandibulectomy with ¢lavic½close and longer follow-up of patients who have under- _aftingrgone excision of denligert.ms cysts should be empha- Surgical Procedure. On May 31 1984 the pat_:sized, was brought to the operating table. The right maadtF_.was removed and cut at the level of the right ce_.laCase Report incisor, getting a 1.5 cm margin of normal bone, t_'A fifteen-year-old female from Rosario, Batangas di_articulated at the temporo-n'landibular joint. Ponu,was admitted to the ENT department of UP-PGH on ofgingival mucosa was also obtained.Ai)rfl 16, 1984 for the first time because of a rightmandibular mass. The surgical defect was repaired by l_at_estind _,right clavicle via a supra-clavicular incision. The'ch_._was di_tticulated from the stern:d end, arid cut n¢_t'a°l,d Prize acromial end, measuring around 6 cm. Alter Ireei_ :_°'1 ,_merl), Residents. I)t'[_l of ()tolaryngology, IJPCM- slernocleidomastoid muscle, ..the cor_tposite graft _IXilI Ihta]lhScicnccs("ctttt.r swung upwards through the skua tun,el between z_.453
_ppcrand lower incisions."Ihe cartilagcn_usend of |he beyond the visible marBLnJof ttmlor and recurrenceIs8a_a¢lew_ shaved ot[ It) expose rile _:uucellous portion tri_Jdy probable if too conservative a surgery is attemptg,dwired to tile manthblc m _ figure of eight fasition ed. Mehli_h et al reported the highest recurrence rate,:a-raga gauge 2t3 s/aiule;_ set'el _il'c, thus tbrnung a free- of 50% in patients who underwent conservative excision.,?,,z:ing myo-osseous gta"t. The mu._,cula_ layer was Our patient experienced two recurrences after_:,i)[_e,! around tire I._orle,'arLd ch..,:_urcin Iayers _as rcmov,d of the lesion. Repeat radiographic examinationL,:,c l_er-dent;fl d_l,l UUcrma,_illary fixation was revealed incomplete septations in the peripheral portionr,,_.,;¢d. A tlast_gastr_,: tttb_: w;_ hl::,exted [or feeding, of the rnandibular mass more suggestive of anmlo-I_be deaths placed v,ith a [,ulb a'.ep_ -syringe kept in blastoma than a dentigerous cyst. Emphasis is th_ made.L,_-ztan_v2egativet_,lesslAxe h_ .,;ucti_rl sec|elions, here to ha,,e a closer _d longer follow-up with patients(;ro_s fiudings re','eaicd lht the right hen_i-matrdible diagno_d to have dentiget_as cysts, since the_ may.;_eularged from the level ,_f the lirst pre-mo]ar up to have an ameloblastic focus which could a3e missed or•' ct_ltdyle, tueasu_ing I._ x ,_ x _) i'm, lhin-sheUed, with there could be proliferating enoplastic epithelial cell,_-_;_g.l'_t)iltj,ball constste_y, lhe m_,D,r teeth were dis- differentiating rote ameloblastoma. Hutton s has report.:iaccd medially. Another t,_oth was attached to the ed a similar ca_ of a fourteen-year-el d female who.i!_'rliOl aspect of the I11',1',:,. ()It ,,pr.u_g ulL the rna._s u_derwent excision of a dentigeous cyst. "I'wenty-one,n tmilucular and cont.'tiiit,(t il sinew.colored, slightly months later, a radiolucent lesion reapl.',eared. Amelo-,._;o_ ,quid. The inner aspe,:t ,if th_ mass was smooth tflastoma was entertained, and the patient underwent a¢tC'e.pt lor _,lle fleshy _u/,_,_wlh_,;dtached to son_e m¢ue _adical refection, tlistopath result revealed stymie._e_sof the wall_ blastt)ma associated with a dentig_t_ cyst.ttistopatli report _:a,_e out with a _eaditlg of "ame- The apparent development of amelobhstoma in the,:_iastonla, ct_mpletely cx_-iscd." A review and coxnpali- wall of a dentige_ous cyst was first described by Cahn in_:mof the previous slides taken du_inl_ the first two ope- 1933_ Other retx)tts were _ecorded since then. A_.though.atit,_s again established a d_._;n_,sisof tlentigerous cyst s_)me _uthors have stated time the rate of occurrence ofa_the fir_ two instances, but the pathologist noted a this phenomenon is high, no accurate tigures could be•'.beuSof su_q)iciou_ amelobl.t_ti_: growth" in the second found. And in spite of the number of rel_rts ofamelo-_¢;of slides. In the latest hist,.._l?zUhologicshdes, a defini-, blastic change in the walls of dentigerotts cyst, evidence::,e picture of anmloblast(_rna was seen, coexistent with were said to be somewhat equivocal. Lucas 6 has men.,_.echara_,teri_ticepithe_ialliningofade,ltigeouscyst, tioned thatevidence toin many reports, there was noshow that the tumor developeddet]nitefrom at,ost_t_pcrativc Course.. It w_ satisfactory and un- simple cyst. Accepted evidence is when it can be de.,,,,tful, I;itravenous i_crmcillul ;uid _.hlotaml_henic_fl n_,,_ustrated that the dentigert_us cyst existed prior tt) the.c_c _3ive_t. a],,_ngw_th I la;_Tl_l]_!,,):;[It.,llesgiven three appearance of ameloblastoma, or when both the lining_:_¢_a &_y. The tube tirair_:_wt-:e r_:nxovcd after one epitheliuua seen norluaIly ill odontogcmc cyst and_,c_.k,She was dl.',chat[r_:Jwith_ut ,:,mq_lications a week arucloblastoma epitlieliu.r are present side by side,a_¢t. Our case satisl]es both of these. Farthemrore, the histo.('lo_e folk_w-up v.as do.,,, witl, tile patient. Weekly patl,_flogie criteria for ameloblastoma set by Vickers and2.:ok.up Ill,de sure 1he;td, ralted clavicle was securely Grulirls 7 are tnet [n our case, na,nely, the hyperchroma-:r,;,olfili,'cd by the i_ter.tbtual :lud inter-rnaxillary tigu_ of the basal cell nuclei of the epithelial l[nhlgofd_e•'_._tt,,,_:_ lhr, v,,,_sreu_oved ;d_,__,,w_th the nasogastric cystic cavities, tile palisading and polar_ation of the•_._eal_er six weeks. No Ie_:u_re_,:e ha_ bee_ noted up ba_al _eU nuc.lei of the lining epithelitm_, and the pre-:c,the prc,_ent time, almost three momhs after surgery. Sence of cytoplasmic vacuolization of the basal cells ofthe cystic lining.[ ts_'ussil,n In our case, the lining epithelium was observed.to beWeale lue._tded he.t,.;wit h a t,t_,¢-fa yotlltl( female Col|Iillrlt)tlS with that formittg the an_¢loblasloum. This,h_, h;_,__uldctgoue tw_ p_evlt,,:,. _:xci._it.is for a ri_t stJplSUls tile theory that ameloblastoma arose by tzans...;,_dibular mass. ]iistop;_tli results el these two opera- fo.H:.tion of the epithelial lining of tim cyst, which_r_s revealed dentige:ot, s cyst, (.lmic:dly and radio- p_obably arises from the onarnel organ .after arneloge-_:_pt_icaUy,early ameloblastoma associated with an nests. This necessitates, therefore, complete removal of.-.erui_tedtt_oth may not be diffe_ent_ate(l from a denti- the deritigerous cyst during surgery. Serial section of_,,a_ cyst since it may be c.,,,sTic,as sta_cd-by llatsakis, the excised tumor should be done in the l-fistopathologic....•',,_n X-ray, it may be no_-spccilic, except for the examinationtutnor.in order not to miss the presence of the•:,l_ilocular radi_flucency which _, very classical. With•:.._rrencesof the mass ira o_r patient, anaeloblastoma Studies by /_lcMillan and Smillie _ showed that._s highly cor_sidercd bcc.ause _._1" the persistent betm- ameloblastoma associated with dentigerous cyst presents., :_, l)etrttgcrous cysts cotdd nt_t result _n .a rapid at all earlier age, six to fourteen years. Dentigerous cysts '::arrem.e after an en bloc excision or ct)n_plete themselves are detected iJ1the younger age group. This,. _it'ztit_l_, Au'_cl,obla_;l_t_a whi_.l_ ha'¢ the capacity w.uhl _tq)port the concept that arneh)blastoum can arise,¢.nt,luetl g_owlh is lil,.cly l. have extensions from th'e walls of dentigerous cyst, c_,t_ary h_ the454
suggestion that such lesions ate ameloblutomas w_iich ration of the patients who haw had thit kind ofl_si_ --'l]dve undergone cystic det,,eneration with coalescence removed. All them would be of great bettefit to ta itof ._ll]aLlcysts to fbr,n a bigger one. If this is so, it would azriving at art early and proper diagnosis, providhag _tbe reasonable to _a_ that such lesions diould appear in adequate treatment, and coming up with a correct_the age group of a:neiobla_toma in general, which is 39 managed patient.yt_amon the avclage ar.d not in a younger age group.(.;ardner9 proposes that a number of important BIBLIOGRAPHyfactors should be cor,sidercd in i)laltning the treatment 1, Paparella, M. ahd Shumrick, D.: Otola_,'yngolo_,of _mlelobl_tomL It is c_ntial tO distinguish among Head and Neck, Vol. III, 1st ed., p. 441, Satmdemthe tl_ee clinical types of amel¢)bla.stoma -- the intra- 2. Batmkis, J.: Tumort of the Head and Neck, 2nd ed.,osseous solid or m,lt-icystic lesion, tile well-circum- WiUiamsandWilkins, p. 533.scribed _Jnicystic type (our case), and the fare peripheralor extra-osseous type . l>e_ause they require different 3. Robinson, L and Martinez, M.: Unicystic Amtk_forms of treatment, l:o_ the s_lid or muticystic type, blastoma, A prognostically distinct entity. Cattc_marginal resection with a 1 to 1.5 crn border of tin- 40:2278-2285, 1977.i,w_lved bone is rcc.:mlt,ended. Segmental resection 4, Mehlisch, D. el al.: Amelobla_toma: A Clinic0F¢.is done it" tilt. iltl'erii_J bolder of the mandible is thologic Report. J. Oral Surg. 30:9, 1972, .nl.trkedly thirm.,'d o) cxp;mded and involvement of5. llutton, C.: Occurence of ameloblasttmla witlda IIhc udjacenl s¢_f'l ti',.,',_':, )s Iptt)bable, as in out ca,_.I',)r the unlcysl t.: h.,,v)tt ,._Ith the tumor limited to the derdigcrous cyst. Oral Surgery. Oral Medicine,cystt_ wall ,t the ha.loll, cnu¢lcation produces com- ()lalPathology 24(21:147.15tl, A_gu_t 196'I.plcle removal When tin tumor has invaded the fibrous 6 l..ucas, R.: Pathology of Tumors of the OrM Tissue,connective tx,_tae w_l), marginal resection should be 3rd ed., London, 1976. Churchill I_ivingsto_tdone, after the initi:d cnuclcation.. Peripheral amelo- chaps 3 and 31:blastomas are excised with a small margin of normal 7. Vickers, R. and Gorlin, R.: Ameloblastoma: D¢,_tissue and the surgical site te-exami_)ed periodically, neation of early histopathologic features of ae_,Curettage produces a high risk of recurrence and plasia. Cancer 26:699-709, Sept. 1970.deemed appropriate in highly selected cases only, like 8. McMillan, M. and Smillie, A,: ameloblastomnin the elderly, when it is desi/ed to spare the patient associated with dentigerous cysts. Oral Surg. 51(5_of a more extensive sdrgery. Cauterization is _'aore 489-496, May 1981. ..effective than curcttat-e alone, and should be used'as anauxiliary tteatment whet.ever currettage is employed 9. Gardner, D. and Pecak, A.: The treatment ofamt/_.to treat ameloblastoma. Radiotherapy is re_erved for bla_toma based on pathologic and anatomic pr_.pies. Cancer 46:2514-2519, 1980.inoperable turners. D.'tngets of post-radiation sarcoma iand osteoradionecrosi:: h;.vc been mentioned by Becketand Peril. (2yotheraphy h:,s been discussed by Marcianiin the t/eatment t)f an_elobl,_stoma but pre_ntly warrantslurthet studies as regards it_ effectivene_.ConclusionThe case of a filt(:eli-year-_Ad fern,de with a recurrentma_dibular mass is t>re.,,ented.Final histopath resultv,,a_ ttmeloblastolua a_st)
•r_ P_. Materials and MethodsJourof (Jt_,)!¢_t & Neck With the patient under neuroleptanalgesia and localS_t;_r:, anesthesia, the em_olization was performed by meansof the transfemoral catheter teclmique. A polyethylenef:rench 5 catheter was threaded into the external carotidartery under fluoroscopic guidance. After identificationt:f the major feeding vessels, a supet_clective internalPRE-OPERATIVE t;IMI_OLIZA'I'ION IN maxalla_y arteriogram,was obtained. Small fragmentsJUVENILE NASOPHARYNGEAL of lyophiUzed dura and gelfoam (approximately 1-2 turnANGIOFI|_ROMA* in diameter) were subsequently injected under t,lmappropriate pressure, usi,lg saline as a bohJs. Severalpieces Of gelfoam strips (1-2 mm x 15 turn) were utilizedto occlude the proxAmal portion of the m',ernal mzxil-Rcne S. Tuazon, M.D,** lary artery. The exact position of the catheter tip wasCesar V. Villafuerte, Jr., M.D.** always controlled before and after injection of theAnne Marie V. l'_spiritu. J.l.).*** paaticulate embolJc' agents by a test in.icction ofEtttrallit_ S. (:tlt'V;ll';l, J r., M.I).**** 2-3 ml. of contrast material.Evelyn F. P:lng:l|iil);tn. M.I).***** Single-shot angiogtapt_ after each enlbolizationwere obtained to determine and document the reduction,f blood flow ut the tuass lesion. The prt_cedure wastexminated when sigmtcant teductitm in the va:icularityI'llcrJpeutlc cml,ohz;ttkm ,f juvt:tfilc angiofrioma of the tumor and slowing down of bltJod flow in thewas performed with ly_duta ail_i gelfoam in a 13-year- main artery was observed. The same procedure was petoldboy who subsequently tmdetwent surgery, lntra- formed tot the opposite external carotid artery.operatwe blood lt_ss wa_ 1,700 ml. An angiographic Fluoroscopy and angiogtaphy wete perfonned usingt:totoct_l is suggested _'hich i2:I_ot ptimarily diagnostic a Televix GE 800 which has a fixed vertical x-ray tube.bat rather aimed: a) to identify tile blood supply of tileFilnls were taken on lateral projection using smg/e Shots.kslon and b) to permit preoperative devascularizationby einboli;_.ation with _lety. No permanent complica- The patient underwent operation 72 hours post.lion occured; earaci_e dtsappeared spontai_eously within embolization.24h¢)ulz.introductionCase ReportR.G., a 13-year.old male, was admitted on JanuaryThe clinical, radiologl¢ and :mgiograpltic features of 16, 1984 to the ENT Ward of the Philippine General)uvenile angiotibroma are well dt_cumented ila medical ltospital for recurrent epistaxis and nasal obstruction.literature,t,a,_ Among the various methods of manage- Three montl_ prior to admission, he had developedmeat of this tumor, surgery remains as tile treatment ofincreasing nasal obstruction associated with slightchoice. The higtfly vascular nature of the angJofibroma, difficulty of swallowing, nasal speech, frequent coryzat_owevet, tw,tkes its remcJval one of the bloodiest proce- and snoring. He began to experience episodes of epis-Jutes in t;cad and neck surgery, Efforts to reduce bloodtaxis on nose-blowing one month prior to admi'ssion.I,d.shave led to the use of various adjuncts in thera?ymcludi_tg vessel lig;ttion, ctyotherapy, injection of On consultation at PGII, physical exanlination_deto._tngagents and oral diethytstilbcstrol, revealed bulging of the soft palate with a 3 x 3 cm.reddish fleshy mass in the nasopharynx. There wasAr_altempt to :educe j_;l_,_)pctativc bleeding withwhitish nasal tlisch:ttge and rctracti,.m _f b_th tympanicti_cuse o[ pret)l)e_ativ_'cmh_,h,_atitm is here presented, membranes. The _est of the I:NI' fintlit_gs were essentiallynormM. Radiologic examination rev,,'aled a soft tissuedel_sity at the area of the nasopharyt_x and h_ine_ ofthe frontal and left maxillary sinuses.,e_.._rtted before the <strong>PSO</strong>-IINS,m August 24, 1984 at the Angiography and embolization wet_: dor:e threeltyatt I_egency ttotel, days before surgical removal of the mass. The left•*l:_,_melly Residents, Dept. of Oto'la_yngology,UPCM- internal max_illary and ascending pharyngeal arteriesP(;ll tlealth SciencesCenter. were identified ,asthe feeding vessels. The internal maxil-• **t_esidtmt, Dept- of Otul'q),ng_,logy, UPCM-PGHHealth lary artery was embolized distally with lyophilized duraSciencesCenter. and gelfoam p:irtides, then proximally with gelfoam,.,.Comultaat, Dope_of Otolaryngology, Ut'(:M-PGittiealth strips. ]'he ascending pharyngeal was not embolized duebcienoesCente_, to technical difficulties. After embolization, pallor of..... Cons-learn, Dept. of R._diology, UPCM-PGI-Iltealth -. the mass was noted. The patient also experienced tnode-S_.icncesCenter. rate left ear pare associate with punctate hemorrhages456
distribuled over the left tymplmic membrane. T]:lis Table 2pare gradually _ubsided and the tlzmorthagel eventuallydisappeared.Blood Loss ha Non-eznbolized CaseslntJ'aOperatively, the n_ilss was exposed via theModified R,ddy Ittctst,)n. "ihe pedicle of the ma_ was Source, Year No. of (gases Average Bloodnoted to be attached to tile left superoposterior naso-- (Loss (rrtl)l>halynx and left terminal e_d of the _ptum. Excbton Conley ct al., 1968 34 1.850of the m_s was d,_r,e and the pedicle removed piece- Jafek et at., 1973 34 2,700meal_ The rema.h_lg sttm_p was ',:ds,)fttlgurated with Christiansen et .,el.,1974 29 1.700elect_ocaut©ry. The rm,:al mucosa and palate were Ward etal., 1974 12 1,300sutured in layers, then a_te_iur and p_)sterior nasal pack- Fletcher et at., 1975 16 2,387ing were done. Blood los_ _as 1.700 ml. Roberson et al., 1979 2 2,400The fhu_ specimen,"obtai;_ed aleasttred 3 x 3 xUP-PCdi, 1979-1983 11 3,5002.3 cm. with. pieces t_f ti_ue with _ aggregate diameter At the Department of ENT, UP-PGtl, 11 cases ofof 1.0 crm Grossl3,, it wa_ zwted to be ovoid, pale, juvenile n_sopharyn_al angio/ibroma managed surgica_ysrno_.,th and f'trna, ltistc_iogic 'examination of the mass without embohzation from 1979 to 1983 were review_l.reve;zledangiof_roma, The average intraoperative blotgl loss is 3,5'00 ml.l)ist'u,_'don In our patient, the inttat,perative blt_od loss was1,700 red. The first 700 rnl was lzst _lufirtg palat',d incl.t'teopcratice t}tetal,et_t_,, e,,iholization of juvenile sion and exposure of the tt_ass aT_dthe surgical field.na_t,halyngeal angi,ffit_,,w.t_ts ha_ been extensiYely Other technical faclots such a_ use of a surgical blad_uti.lieed __nEurope and the ilnited States lbr the past de- instead of cutting electrocautery during the tran.spaht£cade. Its use in :_ug:hcases w'a:;_uggcsted by Djindjian t: incision and non-infiltration of the palate with adrtn_.in 1975. The p_ilt_ary i]_dv:ation is the reduction of line which is a potent vasoconstrictor otherwise routi_¢.int_.t.operative blt._odl,_s_, ly utilized in similar cases could have contributed to th_t_obers
ly resolvedwit/tin a week. Headache and earache were 10. Djklji_m R., CophlgnonJ., Theron J., et al: Embofirrhevedb_yold analgesics, zation by Super_lective Arteriogxaphy from theFemoral Route. Neurotadioiogy 1973 ; 6: 20-26.Conclu:donl 1. Djindjian R.. Introduction a hi technklUe de I'embo,'l'ranwathetcr arterial emholi/ation of tile internal lisation. Embolisation en pathologie ORL. Ann.n_axtllai2, a,tct}' m our )'_,mg male patmnt with jure. Ratliol, 1974.17:605.allc na._ph;ryn_:t'al dil2-_!_'lil,lOl]l_,l proved to be useful 12. l)jindjian R.: Indications, contra-indications, acci-?_c,q_er.ativcly in c,,utlt_lling .,td Irmiting plofu_ dents, incidents dans l'embolisation de la carotide[leeding dul mg surgery. Tht.s allowed complete removal, externe. J. Neuroradiol. 1975, 2: 173.el the tdmm. We feel that emboliz.ation is a safe andVmple procedure in experiemed hands which will, 13, Battakit JC;: "rumors of tlm Head and Neck: Clialcalm the forseeable future, be of major benefit as anglo, and Pathologiea| Considtratiom, ed 2. Baltimore,tibrumas. We hope local e×pericnce will grow and WiliLtn_andWilkinsCo., 1979, pp. 296-300.,,,dl continue to be e_couraged and improved for the 14, Conley JJ, Complications of Head and Neck Sur.maximt.m_benefit of our Filipino patientL gel'y, ed 1. Pt'atadelphia. W.B. Saunders Co., 1979,p. 70.Acknowledgement: Dr. Robertc, Reodica, Chairman,Dept. of Radiology a.nd Cancer Institute, UP-PGIt_,ledical (;enter. Pre-Operative Embolization in JuvenileNasopharyngeal AngiofibromaRetercnce_;1. Waldman SR, Levine I-IL, ,,'ksto_I, et al: Surgical ' ;Experience with N_sv[_h:.:ryn_',eal Angiofibronta>,rch C)folaryngol 1')_1: 107. ¢_77.6_2.2. l.ietchm JD, l)cd,._ Jill, Ncv,'tull "t11, t,'t al: t'reoperatineEmbolization of Juveriile Angiofibromasof the Nasopharynx. Aml titc,l 1915; 84; 740-3 Rohcl_on (;II. Price ,V', I):t',i; JM. ct al: The.I,IIU'IIIIC I'II_t;tlll/,lllllll _11 )_l_,'lllllC Atq,i_Jlibloln;t4 Kat._.ai_ I',, I/or/_.;(;., Ka_,t_niui_(',: l'ran_alhelerA.rtc_ial l'.mimh/atM_ m Na._,_pjmry_._eal Arlgio- t"i_:1. I'lainfilm, lateral viewrevealsthcb_r_._'cnceo.lafibr_.,maActa t_.at!i¢_kq.',iCzt l.)lab'Ilos]', 1'.)79; 20: 433- sc._ft tissue was dens#y at the nas
Fig2.b. Post-emb_.di:_'i_,_: at_.!,h_rctphy shows d_gvasvLt.larizati_.m or the: ma._ apM occhtsion of theinternal m_ilh_r_' _rt_'_ with gelfoan_ sirip._459
ll-_cPh_ the hemansioma, however, the larger lesionsmay resultj_,_,,.,,lOt_,.,in wrinkles and bogginess of the skin such that surgery_,J,__c,:k could notbe avoided.There ate many treatments tried like radiaton,frec_,ingl laser, for noninvolutiri$ hemangiomas and surgel)'t_r tile injection of sclerosing agents for deetx'r ones.'l"attooing to match the color of the surroundings skin111.MAN(,IOM A S .. A _iURGI:ON'S is d_,.e for capillary hemangiomas. Whatever lechniqueI)ILI'MMA* is used care must be exercised that damage to normaltis._ue is minimal, to avoid excessive scarring or dcformityworse than what is beis_g ¢orrected, especkdly iflocated in the face where it can produce distortion,assyruetfy or scarring.Drzt. Nonctte I"lorentino-Florcs** Ca_* History[.)l. Abelardo B. Percz*** A 13-year-old gkl was admitted because of assymetryt_l'the tiace.iler condiliou started 3 years FI'A as _)ft nonteltdcrmass in the left cl_cek. There were u_ accotnpallyingnor aggravating symptoms. Several medications]tema,git)mas belo_l to the g_:rlcralgroup of Anglo- unkrtowtl to the patient were given with nc improve-._a_. 'l'hey ctnlsi.sl of dilltlCtl blo,.)d yes,Is with pools me,t_ The progressively enlarging mass caused rnarked,_:,Ocollections of blot)d; a_ld if it is .superficial it is put- _s),metry of the face. The mass is comprcs_;ible, bepii_hin coh.)r bat if i! i'_deep it flay prcse_lt itself as a coming very prominent upon stooping espe_:ially when_lt tissue nlass, as a blced'..r_l_emergency, as a cause of the head is pusl_ed against resistance.:espir_t_ry dist_ess, or ;_ a ma_ked defi_rmity. If it pre-_r:l!. _tself as a bleedi_g cmcrgcr_cy or as a cause of Physical examination showed a fairly developed,_c_)irzttOr,vdistress, acti,_a mt_t I'vemade 'decissively fairly nourished extremdy shy girl, not hi any foma ofthat deformity becolnes immaterial as life takes priotity, distress, ambulatory, with vital signs ',ill normal_ Theretlul if' _t appea_-s as a st)ft tissue r,_ass or as a defomtity was a mass on th_ left cheek which was suft not well:!.c_ Ihc _,utc.,ne of the t_c:,lment bet.omes real and delineated, compressible non-tender, causing markimi,_H;mtassyMetry of the face.Hemangiomas that ,ire preseul ',tt birth arc embryo- Operative Technique_c _cqucst;'atJot_ of tt:e ,regis)bin:it ru_.)_t;ol'tci_ h)und in:_malc. It could occur in a_y part
l)i_'+cll_siun7. HarryBlackfield, WilliamJ.Mnrrisand FrancinA.Torrey Vi:;ibl¢ llcmangioma: PreliJni_lary Statistical(.'a,,'crn_)u_h_,mazl_,,.u_l_u ill tlne ._olt tissue are com. Report of IO-Yeat Study Pla._tic and Reconstructprc,.::,iblchowever in tl:e f:_ce it is "alsodeforming and ire Surgery, September 1960, 26:32 6-_,.9.2",c, Jll_.)_!ll,.'C$ CXtlCllle c_3tls.ci,_d\l_e_.,',; and Call cause iUlixalcrtt)r_ty complex. It sh.:v,'s gn_wth during pubert), 8. C. Jack |tipps, James M. Iz)wson, Richard E.:m_! l_rcgtaat_cy. 11_ the s_ft tissue the usual order is Straith Tattooiag of Capillary l'temangioma PlasticSl),,.u_taNeousregression but there is criteria to know and Reconstructive Surgery, January i962.whi,:h oltc will bc :,tztti.n._y, rc_,res._,completely ir_- 9. B. (;ray Taylor and Samuel N. Etheredge Heman.w,lutc, or cuntir_t,: it) trr,,w. The _urseon is placed in gioma of Mandible and Maxilla_ American Journalextreme pre_t.tlC by the p_tcnt.,i and patient. 'rhcy Surg.,October 1964, !08:515-577.should be m:tde _,,vare,.d _;p_m_axt,_uus regression, and if•the, _urgcon is f_)rccd I.... t._cz:_te especially that of the 10. Jose-Guerro-Sat_tos, Abel Castancda and J. Antonio/ar_.;eleszorl it nitJ_t be lcme_abered Otat lesions which Barba. Surgery fur Correction of Labi',d Angiomahave u1_dergone a le_v years t_l involution will be of Arch. Surgery May 1967, 94:728-733_hell>. ('are should bc made t:._place the incision follow- I1. Herbert (';obtm_ and Ara Bohcali, |lemangioma.ilq._the lines of cxprcssi,_I_ _,I' the face and preservirag tous P_Ayps of' the Septum_ The La,h,ngoscope,the underlying h_|i)otl:i[It _tlttt:ltltCS like the muscles, March 1!)63, 73:281-287._lc_v,._,_ld die p;_r,,_,l ,h_cI l'¢,._t_,l,e_ative IhatHte _s 12. I".A. Walker Jr. and L.C Mctlel_i-y Primary [lcmaninlw,_rl;mti,i the chalice _,1It:,'hr_i,.luc _JOllla of tile Zygoma Arch Otolaryngology, [;eb.lit IhC t,,:t.')t' ])|CSt'lllt'_J lip' !_.tlli,l[(_gy _cpt)rt api),trcnt- ruary 19t)S, 81: 19().203.ly liitli_.'ated lnv_llt.|tl, lll. IhtlluL', lhc o]_cratit)ll care _,v'asmarie Io preser',c _he u_,t,:tlyirlg tissues and ilt_ision )3. Marvita Ix)ring Hentangioma of II_e Ma_ldible Dizgwasal_)rtc the I..:mgcr's Imc. l>_)s)operative day was l|osis arrd Theraphy Arch Otolaryngology, Junetm_vei_tI'ul. She wz_sdi,_:h:tr,geafter S clays and stitches 1967, 85:645-652.wcrc removed at the ;'tl, day, "rite patient w.'ts seen in 14. Sidney K. Wynn Esthetic Reduction of"Pi._occhio"iwt) weeks alter wilh I,:_,.fly :tuy evidcrice of the (:pcra- ilemangi()ma Arch of Otolaryrtgology, July 1976,tiola except tot a fainl thil: hne _',car.The face is syme- 102:416-419.Irical and there is Ilo swelling ,)n the left cheek size was 15. Claudio Roxas and Abelardo B. Perez Capill_.asked to stoop and pushed hct" head against resistance, l'temangioma Phil. j. Oto. --. 11& N Surg., 1948,The result issatisfying to both the surgeon and' the p. 295-299.paticfit.C()nclusionA brief review of hemangioma was made. Th'e surgicaltechnique with an ilh_stration of a case was presented.("onscrvatisln and cglrerne care in manageme_ltnlust be exerctse for soft tis'_ue cavernous hemangioma.BIBLIOGRAI'HY}. Francis 1.2edererDise;_,.es Of Eat, Nose and Throat6 H.edition F.A. Davis l'hiladelphia 1953, p. 1278.2. Andrew l!ggston ;rod D_rothy Worlf Hestopatho..l,q!,y_t' I_ar. N,_sc :u,I 'l'h_oat, Willi:_xnsand Willi;mts('u, lhdtim,_c 19/,1, p, "/'70.3. 13yror_ ll;_dey Otol._ynl;ol,)gy Ed l'aparella andShutl_ireck W.II. S'auildcrs Philadelphia 1973, p. b534. ltarry M. F;lackticld, Francis A. Tt_rrey, William J.Morris, Bertram VA. Low-Beer Plea for Conservationin Infancy Plastic and Reconstructure Surgery.July 1957, 20:33-44.5. Harry M. Blackficld, Francis A. Torrey, William J.Morris and Bertram V,A.. t._,w-Beer Managementof Visible ll,:ma_gion_a Am. J. Surgery August1957, 94:313-32(.).l_. Philip A. Wci_;m:m Ani,,ioma it_ Lips:' UnresolvedPt(_blcm. Pi_lslic alld I_ec_)_stllrclive Surgery,,July 1961, 28:43-55.461
•__ vhi],,J,_t_r 0 [ I, q(J,(?z_ ReportsI!_J _ :.¢eck B.C., 4;3 years old with Square.us Cetl Ca, floor..t_:!:,:[yof the mouth, left and R.E., 60 years old with Squamous(.'ell Ca, right buccal mucosa were both referred by _.heS:_,,_s Clinic in Maloios to the Ospitat fagMaynila fordefinitive management. Betel nut chewers, pre-operativeevaluation revealed tumor encroachment of the alveolarMO1)IFIEI) SAGI]']'..kL OSTECI OMY OF process in both cases with no radiographic evidence of"ll[[_ MANDIBLE: A PI_.I(LIMINARY bone involvement. Both patients were scheduled forR EP()R'I'* st, gery which included, among other thiilgs, a completeresection of the adjoining portion of the mandible witheventual replacement of the medial lingual cortex ia thetbst (Ca, floor of mouth) and the lateral, buccat cortexi_ the second (Ca,buccal nmcosa).Francisco A. Victoria. M.D.**Jo_ Antonio F. l-(o.x:_s, bl.D.*** I)iscussionIn both cases, there was tumor inwalvenaem of the.dvta_lar proce,_,i without, however, any r_tdiologic cvidc,ceof t_sseous destnlction in the adjuace_lt maJldible.I_.q_lete rcsccti.Jt of the atljoi,ing matulible wa:_ ac-_t.'l_r_l C:[_ _ iCd _tJl , "F]Ic_t:hllz'odtnctiull c,.,ml,li_d_edto_.;ether with the primary le_i.f_. The currcsp_mdinghalf-- either Ihe medial, lint_ual half or theS;t_.,_ttal,steer,rely ,,l :he II,,ll_,li:,]e r, ;I relatively kttelal, buccal half -- was lemoved togclhel with thel_ew, i,l,_vatlve ._utg,'al te_/lflit]lle cmpluyed in ope_a- tumor. Working in vitro, the resected rnar_dible is sepat,,m_withill the oral _a'Aty. m,,;c specilically for lesions rated fi'om the tumor taking care to avoid seedling. 7lie>;tu,lted (.)rilwulvm 8 tile llt),,r .',1Ihe ):_outh, the buccal rcsccted portion of the martdible is thoroughly cleansed:l_u_osa, the h_wcr h_). ton_u_:, a_. well a_ the mandible with Normal Saline Solution; all teeth were extractedlt_el)'. It i'; _ modificalk>_ _.,l marginal _escction of the and with the b(_ne en_e, the mandible was then split_::amlible or the "pull 'h[ut,:.,.h" p,occdu,e. * The differ- in half. "1he petiosteum of the uninvolved half beingt._l_elic_;in the boy c,_ts il; that the s.,eittal ostectomy left undtsturbed aad just befote being placed into posi-A{ows the full heighl ot the medial, lingual cortex tobc split from the lateral buc.za! _,.,_tex of the mandible. _tion, thoroughly cleansed again.Inf_rtu_:_ately, as described by Mazzarella and Freid- The uninvolved half was thea replaced and wiredi,mder, this procedure is not ainpficable to the ascendingr_rnus of the lower ma_dible for a:_atomJcal reasons,back into position with its periosteum, lmntobilizationwas reinforced by inter-maxillary wiring util_ing the uniJwolvedportions of the lower mandible.To ensure success, Mazzarelti a_d [:reidlander insistthat thor.: must be at least one tin of grossly normal Resultst_ucosa between the alve.la: pro,.ess and that the tumor!,.ts __ot infihrated the periostctam as indicated by the While it is too early to assess the long term resultsz_.ohilityof the zum_r ira:el:_t_,)nto the mandible, of this conservation surgery, nonetheless the more complicatedreconstruction with osteomuscular flap consist-At the Ospir,d Ng Maynila, Department .of Otola. ing of the clavicle and sternocleidomastoid muscle withr3rl_,¢lo_v furthc_ iliodil]c:_llOll of tl_e procedure has the use of the lilac crest, rib and the like are avoided,mod_tqcations a_c evert Jnore thus significantly redl.lcing morbidity. If the tumor isct_lP,.rr_,:_tiw., b_h ix_hldlC:liioi_.:nal e_tci_l, hopefldly c_.nlplelely excised, then in terms of ]_hysic.logicwiIholll F._o_;tldl,,,Jll} _.I}1¢]l:,llt.ill's ch_ql;_,'S for SUlViVal lUllCti_ll at|tl cost,erie effect, this techt_ique nnerits'l he m,dffic'al ,.ms azc ',1_, J_,ll,n_s:_c,..gnilion and al)plication.1. Tumor en,:roachn_ent of the alveolar proce_ Advantages:is _llowed provided there is J_._radiographic evidence of I. No rejection or tissue reactionmar_dibulaxmvulvement. 2. Better cosmetic effect2. Tumor inf-dtration of the pcriosteum is not 3. Uncomplicated and easyo.,,_idetcd as this is taker_out anyway. 4. Increased accessibility to tumor3. The mandible is completely rcsected and bone Comment_-_littingdOllC"ii1 VitrO."Thisinnovation isnotmeanttodowngradeprogress•P_c_nt_d on Augt|st 1964. at the Ilyatt Regency Hold already made in this field, most espedally the use ofScientificMe_tingon lntctestis_gCases compound flap of clavicle _md sternocleidom_toid'*(k)nsu/_ant,Hospitalng Maynila,Dept. of Otolaryngology. muscle. HOwever, it is not as simple as it seems as it is•,*Resident. IINM.Dept. off)tt_lar._t;_.dogy, an involved procedure which restores the function of46"2_
I;Ipl,t.'_ll,JllCl_ ;m,d_)llllilll.!Hl;l_"[il_iL'_'l|il)ll+ _|llt+'tllaIl')ll'th:_"!l'llilitlIlI:IS Well ilS ll'le #?\01' lulhw_,,;+,)I'the lower f:_¢c. '3rmaJ.'t, hail_t-I]letl_eus_c,,_;,_.,II_.m,.l[I,Ic _.'ot_,t _,_rIf,, _>,.'Ic.,,.:c'cd I,_e,]mique ;tl_.'nm. :islhereplacrdl-.urthc[m,>,u, if ltlll+t lug Slalt,',t be lcc;.tlh.;d that Call+.:el- L.lOlL,, l)ortitm of Ihc+ m.
464
T_,,_,_'IUL The initial .laboratory studies showed anemia ofJ,_u,ofOto. 88 g/l, elevated alkaline phosphatasc and ESR of 257Ilcad& Neck lu/l., and 62 mm/l'tr, respectively. Che,:t x-ray revealedSurgery hernial findir_gs while x-ray of' tile mandible showed amarkedly expanding lyric lesion involving the. angle andi.mms of tile lelt mandible with marked thitumag of theel,fleX. "l'hcle was no evidence of pcriu:;teal new bonefurnmtion noted. Fibrou._ strand_ were noted wtillin theANEURYSMA/BONE CYST OF TIlE lesion with an area of radmlucency at the upper LateralMANI)IIILE: A CASt). REPOR'I* part. l_rimary hnpre_ion is new growth of the mandibleto rule out the following condition,s: o_ifying' fibroma,adamantinoma, solitary bone cyst.Before proceeding with surger'/ this patient was.Carmencila Vera Cruz-Dizen, M.D. treated with intravenous antibiotics and O_ehemoglobinTeodoro F. 1]am:mzare..s, M.D. elevated with blood transfusion's.Remigio 1. Jarin. M.D. At operati_m on Aug. 27, 1983, the skin was foundRizalino F. Felarca. M.D.to be easily peeled _/'f from the mandit_le up to the angle.The condyle and coronoid processes were obliteratedand they welt fumed to be just. 2 small protruberanceson top to the tumor. Because of the :dzc mlcl extenthmoduction involving tile left rnandible a hemimanOibulcctom) _In 1952, Jaf'fe and l..ichen_tein described what they was done. Post-operatiuely, the cour:_e ,,va3 uneventful.called aneury'lm;d, b
cyst. One is that the cyst is a secondary manif_tation is composed of fibrous tissue and of osteoid in whic.hdeveloping ,in a pre-existing lesi_m altered by hereof there may or may not be areas of calcification. Thererfiai'.e,cystic change, or s
TAI.H.E I1ence for either sex. On roentgenograrnJt has an expa_stle ,oap-bubbte'appearance and extends beyondTRE_'IMI!N'[ PATIENT normal confines of the bc_e, being outlined by a tt_layer of subperioste_ new bone.l_,a,,)i:,tion With Aneurysmal bone cysts are benign and amenable tot'Jiraarv :.1_,,_ 'l'l,_atcd' Rccu_rr._c treatment by curettage and roe_lt_,_ea(!xcrapy. But iaselected cases such as the mandible, resection is tht('.,rettage h,, 4 1 treatment of choice.5'..'_ I 0 This paper has leviewed a tart: er_tity, aneurymudL'_llc:tage and I',;o 1 0 bone cyst, which most often occ:ui's ill king bones andc:ltitc_y' Yes 3 0 spine, less so in rile mandible.( t_iettage, caut_:ty Nt_ 3 1and gtal't Yes 2 0 BIBLIOGRAPHY "Cure'tsage and No 20 7 Aegerter, E.F., and Kkkpatrick, J.A. (19"75) Orthopedicg:.fft Yes 0 0 Diseases, l'hysiology, l:'ath(_logy, Radiology, Fourthl_v,,ccl.ioriand N_) 11 0 edition. Philadelphia. W.B. Saundets Company.g,'aft Yc:, 0 0 Barnes, R. (19561 Aneurysmal bone cyst. Journal of1.3:cisiun N, O 0 Bone and Joint Surgery, 38-B, 301-31 I."__:', I 0 Bieset;kcr, J.[ .... Marcove, R.C., Juvos, A.G., andh_;tdiatioll .'tit)rio 1 1 Mike, V. (19701 Aneurysmal h(me cysts. Cancer,Tt,t al t>2 13 26, 615.625.Donaldson, W.F., Jr. (1962) Aneurysmal bone cystsBecause of tile va_iot_ sites of lesions and that some Journal of Bone and Joists Surgery, 44.A, 25-40.pa;lents were treated aa c:.l) _t_1910 many forms of Dchestein, L., (1953) Aneurysmal bot_e cysts, Furthertrc:_tntezlt had I:,et'_ t2,,cdIll the:,c cases. These hacludcd observations. Cancer, 6, 1228-1237.ex,AsiotL, re._cti'..,n, axtl[)_tt;ttit)n arid various conlbinationsof curettage, cautery ,rod grafting as in the table. Sherman, RS., and Soong, K.Y., (19571 Aneurysmalbone cyst: Its roentgen diagnosis. Radiology, 68,Recurrences devekq>cd m 13 _ases. 54-64.Treatment m
THE 3zd SCIENTIFIC RESEARCH CONTEST(SURGICAL & SURGICAL INSTRUMENTS)INOTOLARYNGOLOGYPresented on December 6, 1984at tho REGEANI' OF MANILA .Sponsor:Medichem Pharmaceuticals, Inc.(Division of United Laboratories, Inc.)468
_l_ePhil.thtu the musclemas_s to subcutaneom. IIt, atof Olo.t[s,_lOIlcad& Neck';ur_,,,:ry b. direct cuttneutts -. in di:'cc't connmunica.tion with perfolator ve:_,els and cour_superficial to the ntuscie tn:_ssesand supplya region of overlying skin.RECONS'I RUt. .... 1i(. )., :, LSIN(.; I'EC'FORAI.ISThe tich vascular supply from the muscle masses toMAJOR M3¢()CrL ........... I ANLOUS , FLAP FOLI, OW- overlyin 8 skin, a compound skin-muscle masses flap canING EXTENSIVE IIEAD AND NECK be elevated without regard to length-to-width ratio asCANCER S/.J]{(.}ERY* long as the muscle masseshas adequate circulation. Theinclusion of segmental vessels underlying the musclemasses furiher ensures proper perfusion thru the perfora.Ad oni.,; J ur;td o, M. It. ** tots to musculocutancous vessels.Rc_te S. ['u:tz.ort, M.I).** The pe,"tor',dis major muscle is a triangularly shapedJose M:tl:ltty:ton, M.I).** muscle which originates as tliree head_:A1)ollo Garcia, M.D.** ]) Clavicular -- anterior aspect of medial half ofJacob M:.ttttl)i!_,M.I).** cl.'t_'icle.Jo.,,cfi_lo llcs'ttatlth:t,, M.|).** 2) St,.'rr'tocosta] - an!erior _urt2tce of'sternum at)dupper six costa] cartila_;c._.Int)(>dttcti()n 3) Abuot't)inal - snt_dl, (fC)Irlthe ap:intt_z:_viable letigt h i_ n,_t acromial vessels just being medial t
chest wound is ch.,'_ed !_z_marily. ter, with a 1.5 x l c_. cervical neck node. He underwentwide ex¢taion with lhe overlying indurated skin, marginal:.' ;,,tc:ll I_J[,.va,d h:l,. It,. p: the' ._lq)'.'ro latelal border of mandibulectomy, al_d RND, light, l')efet:t at ttl_ floor ofII.,- dc:d,.4p,:_l:si._u ! ,,; *.,I,.,._: !_, th_ acromitm. "Ibis had Ihe mouth and buccM area was clc_sedusing the PM[.,.'> ¢._t '_l:lrl¢:.., ? .I]. l:.;4,1j ,_Ii11, w..! t'llccJUnle_¢d a ]')aliellt myocutaneou_ ilap. Skin defect v,,a_ closed with anv.'rl_ I',_l,md'., ',';_l,i;,,]r:.':0,,,:n_v el the p,x: I_dt_ mfertorly ba:,ed bilobed t]ap. t.lnevclatful recoveryl.._,_ch,,.._t_.c !l:cl_. w.: h.._t* m_dili,:d ibis tncisior] role a,_d patient was di_;charged 12 days tx),at-operatively.,,_.:,! wc t_ll ti:,. "d,,t,m_,iv(: m_.i:_,a." 'Ibis is a cmvi. Case 5. P.R., 47/M adnlitted with a diagnosis of!i!.t:.H inc,_i,..m J_.,! l.,,.lc,_.vthe act,.ntit)tt t,a the supero., squamous cell Ca, retromolar area. l::mdings revealed anmedial bot,l_.r uf [}it? (!esi_7ted i.qand. The upper curvi- 8 x 4 mass on left mandible and a 4"x 3 lle._'_y ma_s inh,_ear mc_:,i_m i.,. c..uti:ncd t_) coMorm with the lateral the posterior, third of the tongue. Trismu_ was present.b_,rdcr ,_f an ima!'ln:tr 5, dclt_,pectoral flap. 'Fl_e ratiu[:ale tie underwent ('ornmando, right with wide excismn oflk_r ti.i.,: ia that. i_" evcl .m absence of ihe pectoralis tongue mass. Reconstruction using pe_.:toralis majorllHi:,CleS i$ cncountc_;:d, a,_ a)terttate dehopectolal tlap myocutaneous flap was done. An infectioll with oro-,:'atl +.:;L_.tlybe _ai_ed ;.a_d zx_.,.'.dt_, reconstruct the suigical cutaneous fistl, la developed with subsequent necrosisdclt.__:l wilil,.)tlt i,_i:,.:hi;tt_, it,,.: contralatetal side. Wifh of the flap. A deltoopc..;toral llap was done after extensivesu_l_, the su,gcon w_,'l }]:t_r_ ' lit) d,_ubt ir_ n'tmd that the debridement of the necrosis.,axial ve>._els oi the dolt. ,pect,.._r:.,lfiap has not been viola. Case 6. "[.M., 50/M admitted for mandibttlar mass ofled and. the)efu:l' the _4al_iiity of' this flap is asstared one year duration. Examilsatiu,_ _eveale_i an g x 6 cm.,h_,_ld ,_ be uccc_., t_v t,, u._,._l hard lixed illa5_i on tire right ft!;t[idibu],tr area and a[_, ._a¢_lltate tl.c ,-i.,'_,,,. _1 lilt' ante_ior che.'.l wall 4 x 3 cm. ulcetofungaing ma,,.', ou t:,ln_:iwd area, rigJat.d¢I,¢1, _,,,e .ll:,o h.tv.,., i_,Mil..,..d tl,c design of the islaHd Ilistopathologic studies revealed squalnous cell ('a,l]ai. We have st,tlh.,d u...mg the crescent shaned design m_)derately differentiated. He underwent classical cornoflhe i_hmd flap. "1hi_ ha, m._t only facditated ch),._ure mando, right oral defect was reconst_t_ctcd using pecto-_'_UI ;11_ I1111illlalll,'_.I lit,: ,.)'m:uelry_)l lhempl_lecsl)CCi;llly ,oils major n_yoct_laneous flap. Post.operative course!' u .:!,' Icm_,h' p,l_,,._l., was t:neventful and discharged after two ,_,'¢cks.Case 7. N.M. 47/M admilted with a diagnosis of(Tast_, Sunllnarit',, 1;n'yngeal ('at, right SIP total laryr_gectomy wilh IhND,_a*._v t. S L., 5:,.M. admitted with a diagllosia of right and Amatsu nee-glottis reconstru,:tiun with recur-_.!la,Lll_lJLl:i t','II ('_", l'l'.+_-)i'Of ttte irl,axttlt, right, pre_entcd rcttce. Findings revealed a mid!ine hard neck mass 3.5 xwith ,_ 5 x d cm ulcctol,m_.!'ltin t, m,l_,s altd bilateral cer- 3.5 cm. located above the tracheostoma. There was also¥1C;.d lit)tiCS, 'I X 3 (.ill fill the left. Patient underwent a one by one cm. movable firm mass, left neck area._tdc ,_xcisitm t_/' the mass including Ihe anterior two. Esophagoscopy showed a fungating mass involvinglhmis of the ton!5_e, hcrnhnandibulcctomy and RND, anterior part of upper third emphagus extending cir-!kgtH ;.tlld $_lptahs(:,ld ll_2v'k di.,,'_eCtJt)rl oll the left. q"he t:umferentiaily except one cm. of t×_stm'ior part ofmttat.,[al d_afect v,'as dt>,:d :Lsin), I'M myocutaneous l]ap. esophageal circumference.I'a+tic.+ttwas tliaci;argcd '27,days p¢++t-_aperatively, lie underwent wide excision of ntidline neck m:,ss/'ase 2. tL.F. 50/M. +a:,c ,.,t dermatofibrosarcoma, with upper third esophagectomy; total thyroidectomyheft _axi!la and bucc:d ar_,_ 5/1[' wide excision, developed and RND, left. Esoplxal,e',d reconstruction u_ing a 6 x 5a e,ra,!ually gtowhl,.' mass at the s,te of exc.isio,_ 9 months cm. tubed pectoralis major.island flap anastomosed top_:,'_ to admission. Jl_: had a _';:,.6 ¢t_t at tire left nraxillary tipper and lower parts of esophageal ren'mantz. Patient;_tz] imc_.'_.l aj-ca. Repeat wide excision with parti:d went home atier 35 days. Barrium swallow done onmaxi2]..'cl_.,m5 was done !'",1 iTLvocutaneous flap was OPD basis revealed good pe_ist',sltic.tone and unobstructedll';_ti l'_., ,.5'_VCI II|C irlllA,II.,] ,tt_')','_ alld DP _hlp was tl_;et.l passage of dye.l_ ,,,vt'; ;he .,,Ida* ,!,'l,.'..'l. I'H,'verltl'ul inJSl-t)pt'taliv.._ ('asc X, V.B., 43/M admitted with ,:t dtagnusi'_ of_c,u.,,'_v I'aIlenl sv,_,, '.era h,,_n,' 21 days after alllpUl,l. SqURIIlOUs ,,'ell ('a right but_cal area Ou examinationI_.m ,,I i.q' clap. there was a 7 x 7 cm. fungatmg mass in the right buccal(",,so .a J.M., 4')/1' 'a,.tu_itt_:d with a diagnosis of area with extension to the angle of the mouth and two..,,qttam,_.l.; _:el_ (",1 Ih,_i ,,f ,he m,nn], P.E. revealed a thirds of lower lip. There was a l x 1 cm. upper jugular4 x .! . u' ulcc_ofungatint; m.t_,._'al the. tlo_,r ofthe mouth node. Patient underwent Commando righl with wide,.:
,,xcision o! Ihe t,aa:.s, [thl), and partial resection of the major may be used.llemimandlble. The :nt_aozal defect was closed using 7. Functional deficits are oli_imized since the•tl,e PM major m)',Jcul._l_e,m._flap. latissimus dorsi can very well compeltsate forCase 10, J.';.._),'M a !milled wilh a diagtmsis of file functional loss of the pectoralis major...qaanl_m_ cell (':_ :tt i_.t..,.,)1' the tongue, llxaminatio,_ The only disadvantages of tl:is flap that maybe;_:vc_led a 3 >. 2 ciu _,',:_.,_.,tv'madcd by a 4 x 3 cm. encoulltered is the occasional transfer of hair bearin_mduralioa invulvi_lg '-he b:lt ba.',e and lateral aspect _f skin in re:des and in tb.e female patient, the size of the.tl':e tongue. "il_,:r_ w.'rc ,_i:_)upi',er jugular nodes. Sub- flap maybe limited.It)tat )..,.l(>:;!,ect_t-:), wit)) I",NI), left was done. Reconstructionof t_e defc..'t wa_ ealried out u.sing PM myo- Summary.cutaneous flap_ We have presented our experiences with the use ofCase I 1. N.Y., 71.,M admitted with a diagnosis of the Pectoralis major myocutaneous flap m all patientsgin_,i_,alcatcinL)ma, li×amination showed a 4 x 3 cm alone or in combinatiol) with the deltopectoral flap._)cerofungatiag mass _m the righl lower 'alveolar _ldge Our own defensi_,e i.ncision modificatiol: a_'_dthe crescentand gingivaI :)r_:_. qher¢ were rmlltiple nodes at the sl)aped island flap was alr)odcscr::bed.vpper jug;dar dixie. (.?_)rn:nar_dowas done on the tigl:tend re,:onstrt_cti_,_ d,..nc ,,_itq_,PM major m_,ocuianco,..sti:_p_-'-l)i.icussionacceptable, th:_ li,_l.it._of resectiot: can be extt:mlcd tocn_u[e eladication of the dk,,xase,It has bec,.,mc z,,enel:0l','accepted tl,at recollStl'uctiveefforts are an mtegr:,l [_._r"of tile inl_.]aldefinitive nla_-agement with curative inlcnt. For the surgeo)l, a_med_ith _he knowh;d!,,e ',rod skill tl,at nlajor defects can bewco,_structed ..vi(h(,ut ].,r;:;of fuacti_ln and cosmeticallyFrom 1983 N_)vem!'cr, 1984. tx:ctoralis major wascontemplated ia 12 cases with St. IV oral-pluary_geal_,'al(illOIn;.[. Ira ow: ca,,c v,ilh Poland's _yndrome, theI)-I' flap was empl_)ycd (,w)(Ig to the absence of lhep(:ctoralis. In one of the earlier cases, we developed i.ntecti(.)nof the flap ;tilt! s_._bsequent necrosis, ltowe.ve)',in the majorit:), of the c;)2;cs(10) where the pector',di_major nlyocutaDeot_s flap was employed alone ,:.,t incombma_i,.m with the deltopecto_alis flap, we achievedthe necessary reconstruction without any loss of tuncti,.)n.In our experience, we have observed the advantageof this flap whicl't are:1. It is a one-stage pro;sedure eliminating thenece:,sity fi_ra ,.a,c_md:trydivision of flaps.2. The d,m,)t s_te Is usually c,loscd prilnatily with-()_lt tile i_tretl ol ',kill glalt';.3. The am_ p,::diclc res_oles the neck contourfollowing RNI) and serves to protect tile calorida)tery.4. It can provide bulk to the defect, e.g. mandibular_csecl itm.5;. It can be used to reconstruct even in irradiatedareas becau:e ilhas its own vascular, supply"and not dependem on the vascularity of therecipient site; it can therefore supply vascula_ity_>fthe rccipiel_t _,itc.6. The il_Ipcan easily cove_ lart;,: skin and inucosaldefects since tile enthe skin over the pectotalis4'11
The i'i_iI From _en on, this machine _: been used in similar,lout Ilead of ,_(Neck Ot,_ cases, and hM p)ovcd indispensable m doing intubations_tr_,ct_and tracheostomies.Ma terialsA Supporting Frame (_ction A)I, Metal Platesfiron} IIa. 61 x35 xO,Scm,---" 1IIR()WNOU'I SUCIION MA(?ttlNE* b. 61 x 81 x 0.5 cm. = l2. Angulars (lrun): 0.4 cm. thicka. 35 cm. arm widthl) 35 t:l-n, length = 22) 72 cm. length-- 23) 61 era. length= 2Rodante P. Savalla. M.I).** 4)5)64 cm. length 45 cm, 1,.ngth = 2Emilia,m Aligui, M.I).** b. 6 cm. Arm width1) 60 cm, length = 22) 58 cm, length = 4c. 1.5 cm. Arm widthi) I0 cm, length-':: 62) 20 cm. length = 3l)Lt,'oduction 3. Multidirectional wheels = 4I.)f the different inn d,.>ubt.,;-topsthe list ,[ those wb.ich made 1. Iron Rods,: 2 cnt. diameterh_e ht'a: on ea:h. bearable ar)d e_i_,"_l)le [q ogress and a. 36.5 cm. lerigth = 1_'_vilt/atitm ',vouht not )l;t_e been ',vhat riley are today b. 43.5 on. length =:'2 ¢_ltl_,ut clectdcaty. 2. Iron tings. 4 cm. O.D. = 5In the Philippines while ele.rlrflication became a pet 3. Iron S - links :: 3plolcct t)f the Marco:_ad,,ttnistrati_.n, it is irmm.'al ttmt it 4. iron Plates (round): -0.5 till. thick;i', ,'lectrafication )hat su[tccc,.l ntost ',dt_t'cthe mstitulion 16 _m. D!A = 2,.)I Martial law eSl;,:ciall,,' i_, tltc ca_y I'/_()s wilh tile 5 Metal I(ing('lamps(It,m);16 tln.().D, x0...]cnl.II',,il[131ll })l,IWll,)ll{') plelUdltllt[ ,, ht)l o),ly Ihe m:(nufac- thick = 4_t_ru_!,',eCl()r ))u_.many hu.,,pltal_ 'a_ wctl. '['he mcleased _). Nut_& Belts !//' x 1"-- 4_.,.,!_ ,)1 oil, de,MrtlctI(.)ll ()1 elc,:t:ic power lines, poor7. BIc],'clePedal Axles = 2N._mlc,_a;)cc _f' electric i,',ellcr'.ttL)t'._ a_id lack of spare 8. Rectalagularlron Rod = 1 x 1 cm.[ _ s _ele blamed for the mauy un:;cl,cdulcd br(Jwnouts, a. 6.5 cm. length = 4b. 10 cm. length = 2!.)uring ,,he o.f these brownout!,, we happened to 9, hon Platesh.._e a cardh,puhnonary arrc_,t on a c)ln:)nt]_ old infam a. 4.6x,3cO,5cm.=4a_ _lt'l./tl. :ks in any emergency ca_es, the first step 10. Tire tube interior (Regular Size)IIt.','Jedtj It.) support vital f_mcuons _sto keep the airway 30 cm. length = 2t_._le,_I:rod clear. We had _,uction ,JU,chincs [.>tltat that I I. Wt)oden Rings: 2 cm. thick = 10tiln: they bet anie useless because thete was no elect.ricity 16.5 cm. O.D. and 14.5 tan. I.D.a_d The only available gelteaator v,as out of' order, so_'i_;_t we u:;cd was an asepto syringe ))lll eveB ill tile C. Suction Line Assernblybc';t _'_ hamts, it proved I() hc d)ffit,alt aml tut'te con- I. Rubber tubing: 1.30.D._umm}:, a. 14 cm. lengths = 1ll,tving _),'itnesscdot/r difticult). :) 4th year medicalb. 41 cm. lengths = 2c. 18 cm. lengths= 2st_,d,:nt instead of being di:;courat;ed, ',va,_inspired to d. 54 cm. lengths = 4_'ar.:h 1,0ra ,Nicker and ecunon,icaly way of aspirating e. 14 cm. lengths = 2tt_::'rac})eobr(,tmltial secretions, f. - 98 cm. lengths = 2It, 1980, ,.iu_mg tUSclczk_hip, he began to assemble g. 41 cm. lengtlt_ = 4_h_'m,_cltine piece by piece u/ltiJ ,)nhi_ last day, he pre- h. 34 cm. lengths = 2-t,t_!c,t us w_tI: thas numua]ly iterated suction machb_e, i. 36 cm. lengttm = 1A 6tt h,,tlky, nevertheless it proved its worth for what it 2. T-tribe. Connectors 1.6 cm. O.D. = 9,
5. Stai,fle_s ste,"l tubing 0.5 cm. O.O, equally distanceA hx the tire intedor_, 5 for e_
...._.1___,_:..... . • ..,., /_ /._ ..../+i' ..... - f/," 't !._,"."- '",_:t ,/-5::_-:-. ,;::"!,:2.i ...." _l_,-:-:l 7"", I i "2__,... ::. ' 1 }.,!I- 4_8_,-- -*_X','I i.' ! ,, I................. _....... '1{% ] _........ %=, {__":,;7 ' " ...."";_"I: ,.-" - *"_'°_-,,c_..-,-......;:'°;_"'
Mcchani._m_f {}peration /see section D)Tiffs brt_v,,rl_oUt_.clion apparatus works ozi simul-I.i_le(_)tISexhaust aild stlc t;o[1 sysicnl of both bellows,].)OWllStl'Ol':e Elf !,,(:[]_,W$ llL'p, I will evacuate aJt in:_c_e_ory bottle B, ,,,lth this mal_euver bellowsno. 2il ccmapressed e×pelli_,, a_r in system I.A, 2-B & 2-Awill ensure the ;_on zet_:,_ of ,dr ht suetitm bottles B& C.In the same way d,at beL]o_.vslio. 2 is expanded withl_te downstroke of its. h,tr_dld, air botlle C is evacuateti.'l'hi_ operation utnulta_.ously cc,_r_pressesbellows no. 1_:_dexpel air i_asyste:_a:;I-B, 2-B and bellows no. 1 itself.This simuJtaneo__:s _7_troke and downstroke cemti-I)t>lasly Cleitt¢ a I_eg,_tl_,'c j.)tc2ssu;e oft accessory sut:tif_nb_3ttles B ar,d C. E,.ltlail:'.:_tloli _.)fpressure will ia turnp)oduce a maintained va_-_.ttllnill tile IlU.I.ll], SUe, lion brittlel, ¢)b[ t}|" ('OIlhilll(?lH_lti_cc_:ssityIhe _._)t,w_: (:,,_t ,.r' :_i:_ _i_achinebecame highbt._tit solved or," l)r__,b)cm_t" h:_wng a mach.ine which is_:_at)te_n the absctlce ,_1ele,:tz],:ity and a f',dterit]ggei_c.ta[Oi',BIBLIOGRAPHY1. Aligui, Eirv'dianoM.I) -. personal communication2. lz.nriquez, A_agelM.D. pe_s_>nalcommunication
_ thisl_.:P_.!,,.Ira,It ol ()10,Pathology_I_',:L'J _. 'q_,,_,Tracheal stenosis may not be apparent for weeks o_:. _,:,,_,, evrm months following the removal of endotracheal lubeor ttacheostomy decannulat_of "Ihe development ofh)w,pressure,high volume cuffs h,'Lsf,;n',urtately decre_edflw itlc_dencc of stetlosis, tlowevet, even with their use,tr_c'l_eal stentJsis still do occ'ur, The m_st susceptible"I'I;_._.(;ItEAL R ESIi(TI ION: A SURGICAL patients are those witl_ a low cardiac output with sub_-Oi'TION FOR 'i't_'.ACHEAL quent poor oxygenation of tissues. The damage causedSTENOSIS _ by a cuff may vary from su_rficial mucosa_ injurywith some cicatricial healing to very deep destruction ofthe tracheal wall loss of all the cartilages in tkis area bypressure necrosis artd, ultm_atety, cicatrization of the_unulation tissue that proliferates in an effo:t to heal theJo_fino lterr_an(tez, M.D.** re.jury (Cry)per and Grille, 1969). Frt_m tlli_ very beefAdonks Jurado, M. [). ,,t. description of the basic pathology of the lesk.,a, it can beRonleo Villarta. M,D.** ._en that the degree of stenosis may vary enormouslyand that the evolution of the stricture may :;t.(_panywhereahmg the line short of o)rnplete occlusion of the trachea,even if untleated, zht troductit)n,] _: [' L _ }e ,I :t , _tl[_'_, _e _ ' } I lt_' } 'tic [ _In the ,_dwnt t,]' _l.,_lerrl m_:tl.,d._ az.J te,.:hnMues o[ Surgical Technique (after Ro,_;, 1979)ze_Mctt'd _aferconq_ared to Iff'eoperative evaluation is done to delerrllirle the' 1hJl i{ wa!; few dt.'c;td_:_,:1!.!':)I'atJcnt, have _cadily sub.. exact level of the ste_iosis, d_esize of the lumcrl, and tile.j..th:d II_cll[:,cl',e_It.),.I_flt,_t;;l(_Vl)CSel surgery especially length el'the stenr_sis.::l lhc ',t_)_nce ot p;._;i ill _,e_e[_l anesthesia_ llowevet,c_.mlll]l,.:;lti_:listhat ate ane:,thesi;_.rclated have increasedAnesthesia via endotrache-,d anesthesia tube is best,_,lnumber. One t_t'tltem 1:,tr._chc',dstone':is, jf feasible, iiowever, mtubation through the lumen ofthe distal trachea may be necessary at variocu; stages ofA phenoIucrlal ]z_ctcase i_t the incidence of tracheal the procedure. Through a low-collar incision extendistg ons[crt,,._]:,h:_.,,becm ,_t_ted si_,,.'c twcat,s yeats ago, Aside l_,)th sides t_f the lateral borders of the sternocleidoma._lr,,mt the stellOSi.Sscctmdat?.' _., iv(.,h.'._tl_ede_Motracheal told muscle, dissection is carried down to the prettache_!mubat_,_n which is tl_c most COI:'IIII{,rletiology, other fascia. It may be necessary to damp, di'dde and transfix..a_:.;cs m_l)hcated art: vehicrd',_r t::,.uma, improperly per- the th)_oid isthmus. The area of the ste[tosis ]s locatedt,_mcd lrachet_toufie_..rod c._,_ge:_ital post-infectious in relation to the cricoid. The entire trachea is dissected_;_tlitlk,l')alb_c causes,free from 1 cm. above the stenosis to 1 cm. beiow. If the[n _hc past,, we hay...,hee_: _'ery c.on_;ervative in our a_ea is lower, a sternal split maybe necessary. Damage to_r_.t'_agc'mert'of traci_al stcm_._L_,:_incewe do not want ti_e recurrent laryngeal nerves is avt_ided by Iyeeping thet_.,play :,.t_dtinker w'iil'_lhe an-w:_). We have manad.ed it dissection close to the trachea at its lateral aspect. Thev,_th ,All;_tatJtm_rtt.Il,_, ,ici_;q'c, t:xcisit)/_Of granulation luteral pedicle supply from the iM'erior thyroid arteriest_ssu_:alld inle,.tiou _:tstere td. t:_,_i_._at.)st of the time, we is preterved while mobLlizaing the trachea. A l'tasol_iletl,al,d wc ar_:left with a fua:fli,i)t_on era permanent esophageal tube aids in the dissection from the esopha-I!d,.hYt)Stt)l|}_/, the patient-u,lai_le _._talk aJ_dhaving that gus. ]he trachea i_ incised horizontaliy at the interspace+._r_r._l'.lHl,.' lhclal tube _,n hI_;:ml,.'t_',,rutc(!,,. ucarest the ccx_tct of the stenosis,cutting t(_ but tierIw_ c;v_e.,,of ptc,t _h,t._,_tl,,n :;_em_s_shave bet:l| Iluou_,h the po,terior wall. Sed',d _lJt:e_2 to 3 ram. int,: 1..c_tt,:.I I_J_ , a flute w_,._,.uc there aggressive, thi,skne_ are then made above and below the original_:,c man;h!,ed them surgically with primary te_retion and cut until a normal sized lumen is encountered. At thec.tid h_-eiId arlastulllOS_S,a procedure which we may have upper and lower ends the posterior wall is then incised,htatd t.)l, but wc never dared to do. With this, tracheos, care being taken not to transect the longitudinal fiberst_m_ylul,c is gone within 48 t_)72 ]_outs post..oper:flJvely, of'hemo,_tas_the esophagus.done.The stenosis is then removed and(Jut objective hi d(,mg this i)[t>ccd_]_cis: The following gul[lelines nay be useful ir_plarmhag1.. to determine its effectivity as a method of the anastomosis.stricture managcme_xt. 1. Cervical tracheal mobilization with flexion of2. to determine possible post-operative complica- t.[_ehead. and _xeek yield.': a g_ from 4.5 to 5.9 cm.tim_s of this procedure. Supralaryngeal relea_ yields an additional 2.5 cm. This*.hd Pri:cl_'(,-wiru_eO is accomplished by 'dividing the thyrohyoid muscles**t-,mucrW F.csidcnrs.UI'.|'Gll lleattk Sciet_cesCenter. aad superior cornua of the thyroid, cartilage (0.5 era.)476
;iticl by davidliq.t li_(' dL,,',uhyoJd niel_ibrarle wiihoul',:iitering _.he lumen _( the pharyzix (2.0 Clll). Avotd pl,r, altll rm, r,Jct,olc[;tlll.ig|.._ ltJ the _tq_cfiOi lar_ Jll!,.'al neul'ovascular hulldle.Stc_l,,._l:, i,'_,_;tll,m +1_BI. zii lenilth le_cted by this_itl_lhtJd i,l'lcl,, lilt" b,'.'it J:l_,_'_ll, l:,lS, /¢2. ,_;cl.tJJS,'.........f:.__.... _.=_._i{,ll } + _,. [ I /lllli i'tll #lt./alllld lhl /,ill{,_'_ _' ,". / .:_ .,t ...... ., +| ,_,it_ , ._('i > _ i _',* 'iA+,lll Oilll_li_l_'_llllliit" " %_ ; / t ' .......+ 1
I'-].:rwellt tracheal resec.!ion with ei'M.lo-end anastomo-,.:,;. [IC was ext.ut-,aled :_fter 4_5 hours anti discharged3. The sho,t recovery period.,,l_*:_It)da',:_. Tim stenosis in our patients were 2 and 3 cm. in.':,ix v,ceks post-ope_-:ltion, tie noted recurrence of len[,th. sblce cornfortable This did not flexion present of much tile of head a problem and neck st,_"gically coulddysl_,_:a w]tlclt made t_m: seek. it-atllltissiotl._ Dizect easily yield 4.5 cm. Stenosis less tha_i 4 cm. in ler_gthl:[l}2I{_'llSCt)_]y sh(.)wetfj th,._ presence. ,.,f !.,,rantflation tissue resected by this /nethod offers tile best prognosg,'al 'he _,_t_:ot anastorm_._:i:;.Tl:.e-,....mulation tissue was Beyond this length, tile otolaryngologist may requestc,,_.c l, c.tulerized and i;_lilt_a'r,l with sle.roids. The the help of the thoracic sul_,,eon cspe_.aally hl dealingi..... l,.[,t'r'gl(a_'_,! ,,.'
led to e'arly cpitheli_li_atiot_ wthout stenosis, Recurrent_)tc._u:lisIn also l_o.)_i)>ln _,:spi_atory ultimately havingfa)]ure at anastoJnosis.Ill uncomplt,';Hed ])',_tic_lt_)_e._ection al)&_tomosiasli,)_Hd)_ot pres_r_t Nlu_'hof a Dr(.,.blem.Withi_ 10 days,the patient c(_u!,J leave the: ht)._pital functional a_t(twi_}_, a_, al_atomi
Th*m,il. Interest for further use of iontophorem were ad-J,,.ro!_)to, ranted by sevelal investigators: Crifo et al. s (1979)iIc,td_ Neck perfomled transtympanic iontophoresis of' N-acetyls_,,_x_ycysteine. Passali et al.6 (1983) peffol_ned tran_tympaniciontopl_otesis of mucolytics and antibiotics ir_glue ear;l'annenbaum ? u._ed iodine iontophoresis in tissue scaricduction Kahn (19gO) used hyd.rocortisone iontophoiONTO 1'IIO R I'.'TIC IN ,_;I"R UME NI'* lc::is m post surgical tenqx_romandibular trismus and fort a micro_-lectrtmit: :lpplication for the paresthesia; Greminger s (1980) t_ed peaicillin andOtt_laryngoiogist) t,entamycin ionh)phoresis in the burned ear chondritisand De Itaan ¢t al.9 (1961) used histamine iontophoreststo increase, circtdation of tube pedtdes and largeFxhnund Falcon, M.D. composite grafts.._ ,._(L'sar "v'illafuerle, Jr., M.I). -...... Encouraged with the multiple uses of the ionto-Gil Vicente, M.I). phorctic imtrument, we at the Department of Otolaryn-Jo_e Malanyaml, M.[). gology UP-PGH came up with the idea of developing aniontopholetic i_trument from iocally available partsC(_rtstdt;mt ,kd _i,,ers with due emphasis o_t ecomm W and reliability.Mariam_ B, (':qmtas biD.J o,,,elit,_ Jamid. M I).Materi,'ds anti MethodsA. InstrumentsAliS'I R.\E"I The design of" the instrument rcquires the1%: literature re,: atdarL_ tl_,. _l_,ll'q_le applications of FulltJwing tesl instruments:>_lophorcs_, as su_,.!,,c:;lt:d,_3",,t..ver;dinve._tigatots, were l. Digital Multimeter for tcstiag and precise callic,'ic'wc.]. ,%y;ilf_I;I/,Ii:q)al;HtJs.\',;;; ,le:,_igncdusing locallybratkm;._va_labl.:paJts aJ,d m;dcli:t_!;. 'lhe cflicacy or usefuhlcss '2. Breadboard for ptototyping and evaluation ofUI' tilt,' lllal)ul',qc_urcd ..Ipl)at;dus \v,s tested by using it in the actual circuit; andihc fol'.>wir g ol:)erati,.ms' y)in.,,)tomy withor withouttube insertion, clhnu..)id¢cl,.)l(lv and antrostomy. 'The 3. Accessory tools like soldering iron, wire strip-)_)aclli_;(:,,h_ch was totmd t
C C,__l 2 Fill the ¢_temal ear canal with freshanestheticaq_e appal:,tu., 1-_.'.:.!cii;q:, ol tile following k_cal ._)lution using 4% lJdocame and 1'1000 ¢pine, . , phrme in 1:1 ratio.o,ulamciJt wllh 71, z. t ,c,'.lJ,:t_!. prk'es. ('l'able l)• th'._t (.)uantity Price 3. htsert the positive electrode into tile anestheti_Battery ('_ ','ul_:,) I _ IU.0(I ill lift."ear witholtl touching the skin.h,tcgtat,'d(it,.utt 1 g ltJO.OU 4. ]qace the groulld negative eJ'_:trode . on t}]_P,_t,.mu,._._ctct ('_ l.il_,-._.,l,m:,) 1 I_ 18.00 patients upper forearm using saline soake¢A_uah_, _],etvl 1 1_ 98.00 gauze it_ between the electrode a:-_d the skin.i'l.lstic Bo.,: 1 i,m32.0Ultdl._cc]l:mc(,tls IWJbc:-;,'lc.ld) 1't 40,005. Apply direct current for five tc_ ten minute._ a_one .milliampere. ]'hat includes sixty seconds tcTotal C,_:;t ............... _298.0(I raise and lower the current.I). Instrument 6. Suction out excess solution and perfbrn'The l-t_mt pand ,,I tile i_astrmnent shown in myringotomy with or without tube insertion.Fig. 2 w_tl b,z conll,t_.;,:d .)f: Five patients underweHt Ethm':_idectomy and1. Power :-;wtl,.:h :rod cu:;e,U intensity control Antrostomy for which art c.wen trial u:;mg iontoplmwhich ,.¢mtrol.: ib,..',,t,'tJt leathe circuit rests of 4% 1-idocaine and l% Ephed[-h"m Sulfate iJ2. P_J , l:t:_t_ l!.¢,l_it_,:', tl'tt: presollCe O[ power. ]'1 ratio ;is allother rllt_de uf iw.lucing rapid l_caanestl,esia. We modified the po_;it)v.e electrode t_make it longer and be able to hold a cotlotl pledget-- O ......... '...... I'IIoL L.umla sO we can in._rt il ir_tto IJu."al-ea of"I.hc .r,phenbpalatine ga_tt.;lion and inferior turbmatc!;. -Ihe convenM,;ter tional method af at_csthesi,_ wa_ used oil the othepa_isou by the parietal against i_ulluifllore_is iJldu_;;llleslheshl.g.ur_'llnt Inr.enml.ty Control R,==I,=_ltb_r,la.'rub,, 1.1.= Poni;. ('hJlJ{Jd] +]l J;+Js 1:_4 II'a_ km I
Discumi,m and Conclusion 9, l)e Haan, C. tad Sta_k. R., Changes in El[e[_nt Cir-....... l+i;, ctl_J&_came. Archievcs of Otolaryngology, arid Dmdon,\.',_I. lOi, July 1975, p, 41 _42 I. 2 I. ];'ink, I).G. (edj'"Electronle Engineers llandbot_k,"'+. ('l i, S ct aL 'l'nu,_tytnt_:mic l,mt_q)boresi:, of Mc-G_aw-llill Book., New York, 1975.N.ALebl f y,_tcin l'hama. Rcs. ('cmun. 1l, 5:389, 22, l..inear Application Handbook, National Semilq79conductor, 1980,6. Passali, D. et al. Transtympanic h:mtophu(esis:Pe_son,d Experience. Laryngoscope, Vol,, 94, p,802.806, Junt_ 19V,4,7. °fan_w_bat[nt, M. Iodine luntophoresis in Redt, cingScar q issue. Physical Therapy, Vol. 60 No. 6, June1980,_. Grcmmger, R et al, Antibiotic lontophoresis for theManagement of Burned Ear Chondritis. Plastic andRe,._m.;[ruclive Sutg.ecy, Vol. 66 No. 3, Sept, 1980.482
l'_,ePhil. , meat of.rtasal polypl nard recurrent ethmoidal]o_r of Ofo.iX,ad& N,.',.kpolyps.,_.uz?rr_,Malerials and MethodA total of h_enty.five patients w_th mLsal puly_st.cn I"lonl January 1983 to October 1984 were includedia this study, h-icluded in this prospective stt, dy were.ttEAq _(?4,UTI:ilY A 'I'I¢I':ATMI:NT FOR _,:_tic_ts with i:lt"ana:.'.:l i._)lypa aaxd re.curr,.ua,, na:_:lNA.S:_L t'()i.'YI'S ._. 1¢.t..'.(.'LR I
Tat,le l i li_ts the conm_on ._w,ns re)ted on examtna-|)i_'tlssion,lu.,n. The ftmilitr t_,asalpolyp iz not a true neoplamarather they represent focld accumulations of edema' able I' P:-t:ser_tmg,
ew,_ ii is deemed neccs,_aty l'o) the close ¢oopelationand regular folh)w-up _l" the pati(:nt to make the procedm.ean effective oneB t B L[OGRAPHY]. B,,nes, i.. et al.: FIm&tmcntaLx of Otolaryngol_gy,W, B, Saundcl:; Corp, l_)b,_,2. Mabry R., M,I), i:,h_mal Co._ti,:ostei-iods Injection,Indications, T_':.h:t'_iuc and ('omplicatiol_s; Otola;yBgologyJte;td :.tml Neck Suz'gery 87:207.'211,March-April ] t__9,3. Singson B., M.D., _-'tai. 5dver Nitrate stick for rc.current and tcsJdHal n::sa] pt)Jyl)s; a rediscovery;The Phil. Jc)urrlal o!' ()t
it,,:Ph±within the conf'mes of the posterior triangle of.,_,,.,,+_r_',,, ik,-.! & N,:ckthe neck. The spinal accessory newe at tim:_.,._r:,' point of exit from tim ';terTlucleidomastoidmuscle at the level where fl_e m_,tor ;oottiben of C'2-34 nenzs joins it i_ pre._rved,The main trunk that COtll'Ses tl'lfough the stetttocleidollt;txtoidrutt_cle is cut an,J goes withI'RI'SERVA'III)N I)l. I/IE SPINAL the specimen. The rest of the neck dissectionA _.I.I'..SSORY NERVI.', IN R.M)ICAL proceed in the usmd manner.N_:('K f)ISSECI'ION: (!NAI..UATION3. Patients were requited to have regnilar follow.upO i: A N |(W 'lt:i( '11NIQ t IEpost.operaS ively.4. The patients were evaluated •based on the fol-Celso Ureta, M I). lowing criteria;Apallo Garci:L M.I). A. Presence or absence of should pain.Gil Vicente. M.D. B. Presence or absence of anatomical deformi-Pantejos, M.I). ties as drooping of the shotdder joint.C. Preser_ceor absence oflimitatiota of abduction.'it the shoulder joint.Based on the above criteria one shouJd _vc gradedIntroduction uur results as Excellent, Gt×>d, Fair and Poor. ttowever,"Shoulder Syndrumc" ha:, bccn an incapacitathlg we have to discard this becau_ *11our paitents showedp,)blem m t_ut patients wh.) tm,le_wcnt Radical Neck _utexcellent results.IJ_.;'.,vct.i,_,tt boca.use the spilt.d +'+, t,_cs,,Ajlynerve has been Resul|s:,,ullnels :;acrificed. ']hu :,y1_,iz+,llc :is described byiN,dll,b_I1I.',HIII;'IiS¢.',q_)1'tI'JC l' )ll ,wU,l'. "Iable I:]) pat£im the _iu.mhler j_,it+t AGE (y[s) SEX2) lirnJtati(.m of abducti_l: ,,.tshc_tdderjoint M • F3) aj:aton+JcaJ d,.'formitlc:; chatacter_ed by droop- l J -- 20 ............... 1 - 0!n_ of lhe :lfl'ccted .,,h,>t,ider jomt and promS- 21 +_30 .............. 0 0l_c!_,._,d tht: ,..,:.tpulat :t[td :.houldcr joi_tt muscles. 31 .. 40 .............. (1 : 04) a fiuzcn shtmlder that re:q, result as a con.re- 41 -, 50 ............. .. 0 : "1quc!lCe ot the sylIdl_qne because of muscular 51 .--60 .............. 2 2inau_ivity al_d imbaial_,.c, paJsy and pain. 61 -.-70 ........ ....... 0 : l()m e>l:elicnue telis its that whorl "Shoulder Syn- 71 ....80 .............. 1 " 1..!l_r_c" devclop_.d m our patients, lehabilitation becomes 4 5=9v_:t) dilficutt. The patient affected is handicapped inr_oth hi_ or Eer _ork a,_d d:dly actidt:,es, it is this inca+ Table II:1,acitati_lg "'Sho,_:ldet Syn.Jr'>_ru" that led us to pursuetl,/,sstudy. Site & Type of Stage of No. ofThe purpose of ',his paper, is to present and evaluate Pt-imary lessions the disease PatientsJ techmque of prescr'w_g tEe-spinal accessory nervefur+otters with_+ut c_mll)tOnli_ittg the radicality of the A. Oral Cavity.c_kdl.:,cct_un.I, Tongue(Epidemmid)a. Anterior Stage IV 1Maleri:.ds ;llld Metholts b. Posterior Stage II I1. rh_s is a prospective _tlJdy of 9 patients admit- 2. Gingiva Stage IV ited in the DcpartIner:t of FN'I'+UP-PGH from (Epidermoid Ca.)Ma_:h to ()..:tober, 19,";4 for va.ri0us malignmv 3, Palate 1ties of the t_e;,l a_d neck wee underwent w_deex_ision with r'.tdic.d t_u_:kdisst ction,(Ca ex Pleomofphic Adenoma)B. Nasal Cavity I2. ] echnique of oper:t_,ot'+ A technique for pre. (Epidermoid Ca.)_:i',ati,Jn of the spiLal ,tccSSol'y nerve function C. Thyroid Glandin radical neck disset.tiun as described by Weitz, 1. Papillary Ca I.el. :d, was followed A _;iassicaJneck dissection 2. Type, Umknown Ii,; .lot_,: itl it._ u:nl.'_l_+_;u_ht'Jwith ;_modification It. Larynx, Glottic Stage IV l486
(l'_pidt:mluid f'a ) Discussion,jt', bubmarldih.lar t,la:.t l *'Shoulder Syndrome" is an incapacitating r,cqueL_I l'yp,-, t.rl_kn_,Wl_ of Radical Neck Dissection. Many attempts have be_l,,hh. Ill ,done to restore shoulder functi,.m. Harris, attemptedplinlary glafthxg I_l" tile severed l)r_Jxltital and distal, all*n; Iv|,t ,,I i:,th .... d,. }tt'*llilcglc, t., _h, ttJlllt'Z SitJlllp$ t)f tile SAN (Spillal Ace:isoly Nerve) by inter.()Iglaltt,ll ll,ct,!',dM5 StatUS t_:_latLngthe great auricular nerve ,ts free graft.tai.,:,1.: Dewar reported on the F_cial sling fixation of theI. _lt'Idt:t'.Xt'lalt'li second and tturd dorsal vertebra/ spines to the root ofM.mdibi.i.,(.._>;y ;,'.._rw (--.) l-xcellcnt the scapular spine and transplanlation of' the levatorg;qt.L _t _ scapulae to the outer end of the scapular spine.'Z '0,',1_:ex,.i_.,n Saunders arid Johnson have described physic',d the.Marl:it:alM,m, laphy rehabilitation program cotl:;isti]ig of the series ofdiO,lc.-t_,:,,/ iI., N ,m. (.) I-:xceUenl exercises..A.][ Of"these lnelhotl.; air: tlesigr.bed to improveRNt i. t£ ; the functionally cmnprollfised shoulder.RND, (R.I All alternative to all these techlliques is the preserrationof the spinal accessory nerve function tkcreby4 T.tal 'lh).r,,t- .',,,uc (,,,) Exccllen't a_erting development of"sh-)uJder syndlome. '¢ltt,.,1.al_x,:, 1¢[,,I), ,Ig.N.,,,I,:P.,,.Lu_:..,! ] The tedmique of" preserving the Spinal AcessoryNerve Function m Radical Neck Dis.vection makes use5. ']'_ll,d 11:,';,,_ T;,;w (..) I.',:_t:clR'ntd.:cl_m :,. l.'}xl_,_l,_of the little known anatomic_d fact that the Tr:.lpezituN,,,tc Iht:km>',I;I muscle has a dual ilmervaY.ion. It is a well known factthat the lllaJn trunk of the Spirnd Aces_a'_ry Nervecourqng lilrough the sternoclei,,lomastoid rrmscie goesMa)_dlb_d._t,)n)_, distally ta tclnainate and supplies the trapcziua muscle.l_t,'_p.(l_ Wlt_t is' not popularly known is that the trapezius7 "lotal l..,_ :';..w: (.-) Excellent muscle' has a second Jnnvervation. "/his comes from ther,,',,'_'.,_.', i' _i_ motor rout of Cx .-.3 -4 which lair, the Spinal Accet-(.13nod, I,itkip,. sOry Nerve trunk. 1"his portion is located on thepre.t.lt) vertebral l.lscia plane arid also at the posterior trianglevl. Wld,_l_.:m,m N,,,,r t-) I';xcetlc]lt of he neck which makc it relatively .safe from any1;,ND. tl¢.l cancer bearing lymphatitz.9. WMeIL_,t:..i..m" N,,_tc (-) ExccllemRNI),(E) Rouviere describes the Spinal Accessory Nerwlymphatic chain as cons_ting of' 5.-10 lymph m_,de_which art'. bltimately associated with Spinal Acces.laMc I _mws a _,_t:2 at 9 patients who undc,,wcnt sory Nerve after it reaches the sternocleidomastoidRNI). blaj.rvy t_f ,_/]: i,aticrA:_ belong to ages, _a_aging nluscle and as it crosses the po_,terior triamgle of" tMItem 5(.i to (',O vear_ _.'..! ()ur)otlngest patient was to neck t¢_ pierce the trapezius muscle, lie 111elltionfd oj?Cal:i t),,:The_e I I. w.:a I;' :.i!milicz, , n_ sex prcdilectltln in the uppermost l:_mim_ (SupelioO which are dosel!_associated with the highest _ode of the jugular chair_,l,r series. ;rod the lower most nodes (inferk.'-) which lie deep tcTaNe 1! shawl; t],,,_ ,:l,._st of our patients have Cat- the trapezius muscle. It is this inferior nodal group thai_.lnOllla _)f" I],,e ,,ra; ,.'.l_jl, f_,ilc_,vt'd by Thyroid, Nasal some autl_urs preserved sitace they are adjacent to th__'a,.'_ly. l.a_)i!x ;,i,d :.t_i_t,l,trl_ll!,ulal glaltd. As with ,ltl_er Spatial Acces,,a_ry Ncive after it _.xi:,'; flora tile sterna.,:ll_'s, I'iI,id.::m,>td _._,:;_,tI,:, predominates in ,_ur cleidomastoid mu_.:le and bet't_re it enters the trape.II_,!y, anti at,', u,,ua' ?,", ':t lalc _;_tile disc:,,_e, zius rmlsde, it lies within the pal, rotifer triangle ofab;e I]1 :,hvw,, il! _. l_l,t old 2' of our patio.as tile ueck.tli_derwcilt w'ttlc c,,;c_',,,,tl _)1' the prmaary lesiou with Skulnik and his colleagues as welt as bit GavranRadical Neck lJis:;c, Ii,,:, In '' .',, our t)atients tile Spa.hal Bauer anti Ogura reported that the posterior triangle o,St:rosary• N,..r.,c ' " ;it the l,.'v,:l where the motet _oot the neck has not been Jbund to be the site ofmeta_tasi(ibe_ of ('_ -_ _ .i.._m'. i_were preserved. Nolymph in their respective series. This prompted these authorl_e in','_lvc_mrr_t ,,i !ha: [>c.A,::it,r Neck tri:tIlgle were to st.l['gest preservation _;f the entire pc:,terior triangl.iisdoscd int_aoper.ttiv,.'J)' .lnd i..i:..tc.,lugically, of the neck, including tile Spinal Accessory Nerve L'All pat_,_ts _,.:rc fc,I!
l',os(erior triangle. 'Thi,.sL,perk)rSDm_d Ace_soryModald;:.n arc intimatcly)elat_:d,vi)h_tcmoicleldoma.stoidJJm_,,:ie a:_duppel jugulJrch:,inof nodes.Thisportion_)ilhc Sl,:na!AccessoryNcr_,',i.,l:)iox.inr, d it)tlult |x)_'-I_,,_v_ht,),: the m,_{,,tI_l,('r c_'[h,'(_ ,) ,_nerve joinI_,h),,l tll,'(t'hm_ ]h,;ps to _,_) _ _I, fh,'_;.,'cmJcn()u!_&md isuncomi.,mm,:)m_;, We stilltakeout alltiv.. snuct'._res of the p,,_,tcnor t:i,mL,.le of lhe neck as inIL_: cla_;i..,)l m_ck tliss,:,:ri,.m with tl_,: exception Of thei_.:_[ti_)nt):' ti_e Spinal Accessory _crvc wi_ere the Inotorof ('2 -a 4 jL)inl i!, unle_,_>a _.,,ros._mvolw_'nlent is noted.'[},c _l,.)xirna] part of th,: 5I)mal Ac-e._::,oty Nerve has_-') k',_)with th_ specim_.)x m mai.rlti._m the radicldity ofthe p; t;.ccdi,rt!.Sl_lflltll_ll_' ' "Nine p'_tients admi_led h_ fl,,e i)ept, of E.N.T.-UP-P(",ll Medical ('t:llltti" tm.lcrwcr,_ (.1:ahtal Nc_k Dissection!'t,r ,'a_im_s p_imary ma[i,v.n,)n_ic, ,_'. lhe head and neck.I'i_' lccbniquc )011o,,vs tile usu:tl re:tuner _s m the classi-,.xd acck di,sccli(m witt? the modHi_.ation based on theinc_:tvatkm ul the portion _)I the .Spinal AccessoryNerve at _}_e !evel whc_e the motor root of C_-..3--.4r_c:vcs join) it. In all ou_ ca._e',, n
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